Heartland Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marcus, Iowa.
- Location
- 604 East Fenton Po Box 608, Marcus, Iowa 51035
- CMS Provider Number
- 165397
- Inspections on file
- 16
- Latest survey
- September 25, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Heartland Care Center during CMS and state inspections, most recent first.
A resident with a history of respiratory failure and other serious conditions experienced inadequate respiratory care when staff changed oxygen therapy from scheduled to PRN without proper monitoring or consultation with the resident and family. The resident's oxygen levels repeatedly dropped below safe thresholds, monitoring frequency decreased, and documentation was lacking. The resident became lethargic and cyanotic, ultimately requiring hospitalization for respiratory distress.
The facility failed to follow the menu as written for one meal and did not ensure that menus were reviewed and approved by a dietician. Incorrect portions were served, and changes to the menu were made without dietician approval, leading to a deficiency.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Observations revealed greasy stove hoods, improper glove use by a cook, and food temperatures below the required levels, violating facility policies and FDA guidelines.
A resident diagnosed with c-diff was discharged without a required discharge summary that included a recapitulation of their stay. The DON confirmed that the recap was not completed as mandated by the facility's policy.
The facility failed to ensure that restorative care was completed as planned for a resident with Alzheimer's and a seizure disorder. The care plan required passive ROM exercises for both upper and lower extremities 5-7 days per week, but the facility did not consistently perform these exercises. The DON acknowledged insufficient staffing on weekends and lack of documentation for missed sessions, while the MDS Coordinator had not conducted recent follow-ups.
The facility failed to provide proper care and services to prevent infection for a resident with a urinary catheter. The resident's catheter bag was improperly placed on multiple occasions, and staff did not follow correct procedures for catheter care, as outlined in the facility's competency assessment.
The facility failed to educate and offer the pneumonia vaccine to a resident with COPD, lacking documentation of vaccine receipt, education, and consent or refusal, despite the facility's policy requiring it upon admission.
The facility failed to ensure that a resident had access to the most recent COVID-19 vaccine. The clinical records lacked documentation that the resident or their responsible party had been educated on, offered, or received the 2023-2024 COVID-19 vaccine. The DON had not yet asked the resident about the updated vaccine, despite CDC guidelines recommending vaccination to protect against serious illness.
Failure to Provide Adequate Respiratory Care and Monitoring
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required supplemental oxygen therapy. The resident, who had a history of respiratory failure, coronary artery disease, renal insufficiency, pneumonia, and sarcoidosis of the lungs, was admitted with a care plan specifying continuous oxygen at 2L, to be increased to 3.5L with ambulation. Despite this, staff changed the oxygen order from scheduled to as-needed (PRN) without increased monitoring or proper consultation with the resident and family. Documentation shows that the resident's oxygen saturation levels were repeatedly below 90% on room air following the order change, and there was a significant decrease in the frequency of oxygen monitoring. Therapy and nursing notes indicated that the resident experienced significant drops in oxygen saturation during therapy sessions, sometimes falling into the low 80s and requiring time to recover. After the order was changed to PRN, the resident's oxygen levels were not checked as frequently, and there was a lack of documentation regarding the rationale for the order change or communication with the family. Staff interviews revealed confusion about who authorized the order change, and the primary care physician was not familiar with the resident or the change. Family members reported that the resident was taken off oxygen abruptly without discussion, and observed him to be lethargic, shaking, and cyanotic prior to hospitalization. Ultimately, the resident was found with oxygen saturations in the low 70s, was placed back on continuous oxygen, and was subsequently hospitalized for shortness of breath, weakness, and pulmonary congestion. Facility policy required that residents and families be informed of new orders, especially those related to changes in condition, and that nurses observe and document signs of respiratory distress. These procedures were not followed, leading to inadequate respiratory care and a negative outcome for the resident.
Failure to Follow Menu and Obtain Dietician Approval
Penalty
Summary
The facility failed to follow the menu as written for one meal and did not ensure that menus were reviewed and approved by a dietician. On 4/3/24, the noon menu included specific portions of creamed chipped beef, mashed potatoes, green beans, and bread. However, Staff A, the cook, served incorrect portions using different scoop sizes. Staff A and the Dietary Manager (DM) were unable to identify the correct scoop sizes, leading to discrepancies in the meal portions served to residents. The DM acknowledged that Staff A gave extra chipped beef gravy but did not adjust the other portions accordingly. Additionally, the facility's menus from Sunday through Saturday had changes made in writing, but none were signed by a dietician. The Administrator and DM confirmed that the facility had been without a dietician for some time, relying on a dietician from an affiliated hospital who visited once a month. The DM admitted to making changes to the menu based on residents' preferences without dietician approval. This lack of oversight and adherence to the menu planning policy resulted in the deficiency noted by the surveyors.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation, the stove hood appeared greasy and grimy, and the sprinklers above the oven had a greasy feel with fuzz hanging intermittently. The Dietary Supervisor was unaware of the last cleaning date for the hood, and the Administrator confirmed that the oven hood was not on the cleaning schedule. The facility policy required stove hoods and filters to be cleaned at least monthly, but there was no record of the last cleaning before the recent one on Monday. Additionally, during the noon meal service, a cook wore the same gloves throughout various tasks, including touching multiple surfaces and handling food, which violated the facility's policy and the FDA Food Code 2017. Furthermore, food temperatures were not maintained at the required levels. After serving the main dining room, the temperature of the mashed potatoes and chipped beef gravy was recorded at 120 degrees, below the required 135 degrees. This failure to maintain proper food temperatures was against the facility's policy, which mandated that all food be cooked, held, and served at appropriate internal temperatures.
Failure to Provide Required Discharge Summary
Penalty
Summary
The facility failed to provide a discharge summary that included a recapitulation of the resident's stay for a resident who was discharged. The resident, who had no cognitive impairment and was diagnosed with enterocolitis due to clostridium difficile (c-diff), was admitted to the facility because he was unable to care for himself at home and experienced severe diarrhea. The resident's baseline care plan indicated that he was receiving physical therapy to regain strength and had good family support. On the day of discharge, the resident packed his belongings, received discharge paperwork, and left the facility with his family. However, the clinical record lacked a discharge summary that included a recap of the resident's stay, which was confirmed by the Director of Nursing (DON) who acknowledged that the recap was not done as required by the facility's policy. The facility's undated Discharge Summary/Recapitulation Policy mandates that a discharge summary, including a recapitulation of the resident's stay, be completed for every resident at the time of discharge. This summary should include diagnoses, treatments, therapies provided, and a final summary of the resident's status. The failure to provide this required documentation was identified during a review of the resident's clinical record and confirmed through staff interviews, highlighting a lapse in adherence to the facility's discharge procedures.
Failure to Complete Restorative Care as Planned
Penalty
Summary
The facility failed to ensure that restorative care was completed as planned for a resident with Alzheimer's disease and a seizure disorder. The resident, who had long and short-term memory problems and severely impaired skills for daily decision-making, depended on staff for activities of daily living. The care plan required passive range of motion (ROM) exercises for both upper and lower extremities to be performed 5-7 days per week as tolerated by the resident. However, the facility did not consistently perform these exercises as scheduled, with numerous weeks showing incomplete or missing sessions for both upper and lower extremities. The Director of Nursing (DON) acknowledged that the days marked as 'not applicable' could mean the resident refused the exercises, but there was no documentation to support this. Additionally, the DON admitted that the facility lacked sufficient staff to perform the exercises on weekends. The MDS Coordinator, who oversaw the restorative program, had not conducted any recent follow-ups to ensure compliance with the care plan. This lack of adherence to the prescribed restorative care regimen was identified through record reviews and staff interviews, highlighting a significant deficiency in the facility's care practices.
Failure to Provide Proper Catheter Care and Prevent Infection
Penalty
Summary
The facility failed to provide appropriate care and services to prevent infection for a resident with a urinary catheter. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was observed with the catheter bag improperly placed on multiple occasions. On one instance, the catheter bag was hung from a garbage can, and on another, it was found lying on the floor. The resident's care plan included specific interventions to monitor for signs and symptoms of urinary tract infections (UTIs) and to provide catheter care, but these were not adequately followed as evidenced by the improper handling of the catheter bag. During pericare, staff were observed using improper techniques, such as placing an incontinent pad before removing gloves and not following the correct procedure for cleansing the catheter. The Director of Nursing (DON) acknowledged that the catheter bag should not be hung on the trash can. The facility's competency assessment for catheter care outlined specific steps for cleansing the catheter and genital area, which were not adhered to by the staff, leading to a failure in preventing potential infections for the resident.
Failure to Educate and Offer Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were educated on the options for the pneumonia vaccination and given the opportunity to accept or decline it. Specifically, for one resident, who had no cognitive impairment and was diagnosed with chronic obstructive pulmonary disease (COPD), the clinical record lacked documentation of receiving a pneumococcal vaccine, education on the vaccine, and a signed consent or refusal. The Director of Nursing (DON) confirmed that the resident had not been offered the pneumonia vaccine, despite the facility's policy stating that all residents would be offered the vaccine upon admission, with risks and benefits provided to them or their representatives.
Failure to Ensure Access to Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure that residents had access to the most recent COVID-19 vaccine for one of the five residents reviewed. Specifically, the clinical records for Resident #6 lacked documentation that they, or their responsible party, had been educated on the 2023-2024 COVID-19 vaccination, been offered, or received a dose of the vaccine. This deficiency was identified during a review of the facility's records and staff interviews, which revealed that the Director of Nursing (DON) had not yet asked Resident #6 about the updated COVID-19 vaccine. The DON stated that some residents received the COVID-19 vaccine at the clinic, and she administered some at the facility. Initially, she had to obtain 10 doses at a time, which required enough residents to express interest. However, she mentioned that it was now possible to get fewer doses at a time. Despite this, Resident #6 had not been approached regarding the updated vaccine. The CDC's updated guidelines recommended the 2023-2024 COVID-19 vaccines to protect against serious illness, emphasizing the importance of vaccination for individuals aged 5 years and older, and particularly for those who are moderately or severely immunocompromised.
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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