Hillcrest Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hawarden, Iowa.
- Location
- 2121 Avenue L, Hawarden, Iowa 51023
- CMS Provider Number
- 165245
- Inspections on file
- 26
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Hillcrest Health Care Center during CMS and state inspections, most recent first.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
Failure to administer ordered meds and notify the physician of missed doses and weight change. Three residents had multiple ordered meds documented as unavailable, not found, or on order, including PPI, antidepressant, laxative, diabetes, and pain patch therapies, with no EHR evidence of physician notification. Another resident with a BIMS score of 9 had major weight fluctuations across facility, hospital, and dialysis records, and staff and the DON acknowledged the physician should have been notified of the discrepancy.
Delayed call light response was documented for multiple residents with varying levels of assistance needs, including residents with intact cognition who reported waiting more than 15 to 30 minutes, and in some cases up to 45 minutes or about an hour, for help. Residents described being unable to get timely assistance with toileting and personal care, while staff confirmed overnight shifts with only one CNA for part of the night and stated call lights were not answered within 15 minutes because there were not enough staff. The DON acknowledged staffing concerns, agency dependability issues, and prior grievances about excessive call light times.
Food Served Below Required Temperature: Two residents with no cognitive impairment stated meals were often served cool or cold, and one resident said staff would not reheat food if asked. During a tray observation, dietary staff checked an enchilada and found it at 129.6 degrees, below the facility policy requirement that hot foods be held at or above 135 degrees F. The Administrator stated food should be served at safe temperatures.
An LPN failed to perform hand hygiene before and after medication administration while giving oral meds and insulin to multiple residents, and continued handling medications and supplies without cleaning hands between residents. The same LPN also administered enteral tube meds to a resident with a PEG tube without wearing the gown required by EBP, despite a posted EBP sign and the DON’s confirmation that gown and glove use were required for that care.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Two residents who were cognitively impaired and dependent on staff for personal care did not receive bathing assistance at least twice weekly as required by facility policy. Facility records showed multiple instances where bathing was documented as refused or not applicable, resulting in gaps of 6, 7, and 11 days between baths. The care plan for one resident specified total dependence on staff for bathing, and the facility’s policy required showers to be offered at least twice weekly and on the next available day if missed. The DON reported that staff are expected to continue offering showers and try different approaches after refusals, but the documented bathing intervals did not reflect this practice.
Resident funds were not accessible 24/7 for two residents. One resident with moderate cognitive impairment and another resident with no cognitive impairment could not reliably get their money in the evening or on weekends. Staff said only the SSW/SW had access to the petty cash box, and the Administrator acknowledged residents only had access when that staff member was at the facility.
Failure to properly complete CMS form #10123 for a resident related to Medicare non-coverage notice. The Social Worker documented that a 48-hour notice was waived, but could not explain or locate support for the waiver, and the ABN Part A did not address the required NOMNC or 48-hour notice. The DON stated she was not familiar with ABN requirements, and the Administrator said she was not fully educated on ABNs and expected the Social Worker to follow the guidelines.
A resident with anxiety, depression, and moderate cognitive impairment continued receiving quetiapine after a physician ordered it discontinued. MAR review showed the antipsychotic was still administered across multiple months, and the DON acknowledged it should have been stopped when the order was signed.
Missing discharge recapitulation of stay. The facility failed to complete discharge summaries for two residents who were discharged from skilled services. Both residents had no cognitive impairment on BIMS, and the records showed discharge-related billing changes and discharge plans, but the charts lacked the required recapitulation of stay, including diagnoses and course of treatment. The DON stated that if it was not in the assessments then it was not completed.
PASRR Level II recommendations were not fully incorporated for multiple residents. One resident with major depressive disorder and schizophrenia had a required psychiatric medication management service delayed because of payment and payee issues, while two other residents had current MDS and diagnosis lists showing anxiety, depression, hallucinations, or schizophrenia that were not reflected in updated PASRR documentation. Staff acknowledged the PASRR should have been updated to include the proper mental health diagnoses.
Failure to update a resident’s comprehensive care plan after a PASRR Level II outcome was completed. The resident had moderate cognitive impairment, MDD, and schizophrenia, and the EHR showed care plan entries that were not timely revised to reflect PASRR-identified specialized and rehabilitative services. A Service Matters review found the NF was not compliant, and the SOC and DON acknowledged the care plan should have been updated promptly after the PASRR was received.
Failure to document and provide catheter care for a resident with a chronic Foley catheter and a documented UTI associated with the catheter. The EHR had no care plan, tasks, or MAR-TAR orders for catheter management, and staff acknowledged there were no documented orders for emptying, output recording, or cleaning the catheter after the resident returned from the hospital. The DON confirmed the missing orders, care plan, tasks, and output documentation.
Improper PEG Tube Medication Administration: An LPN administered medications through a resident’s PEG tube using forceful pressure on the syringe piston, stating she had to use force because the syringe was difficult to push. The resident required bolus feeding via PEG tube, and the facility policy called for medications to be given by gravity or gentle pressure with water flushes before, between, and after medications; the DON stated she had no concerns with pushing the syringe piston.
Failure to Address Dementia Care in Care Plans: The facility failed to include dementia-related care in the care plans for two residents with documented dementia and cognitive impairment. One resident had Non-Alzheimer’s Dementia with moderate cognitive impairment, and the care plan lacked dementia care information despite the facility’s policy requiring person-centered dementia care planning. Another resident had vascular dementia with severe cognitive impairment, but the care plan did not include individualized interventions such as verbal, behavioral, or environmental prompts.
An LPN administered insulin to a resident using an insulin pen but did not perform the manufacturer-required 2-unit safety test before giving the prescribed dose. The facility’s insulin policy did not address insulin pen use, and the DON and Administrator stated staff were expected to follow hand hygiene and manufacturer instructions for insulin pen administration.
A resident with HF, AFib, HTN, and moderate cognitive impairment had highly inconsistent recorded weights, including large losses and gains across multiple entries. The clinical record lacked documentation explaining the fluctuations, and the DON stated staff should have questioned the significant changes and obtained a re-weigh or follow-up when the weights appeared inaccurate.
The facility failed to maintain a comprehensive and effective QAPI program with a plan for QAPI and QAA activities. DIAL visit history showed repeat deficiencies from the prior annual survey and the current survey, including F582, F584, F677, F684, and F880. The facility's QAPI policy stated the program is intended to continually assess performance across all service areas and support person-centered care.
The facility failed to have a trained IP present at its quarterly QAA meetings. Review of QAPI attendance records showed no trained IP at the meeting, and the QAPI policy required documentation of meeting dates and attendee names/titles. During interview, the Administrator stated there was no IP with training present from October 2025 until the current IP received training at the QAPI meetings.
A resident with severe cognitive impairment and multiple falls did not have updated fall prevention interventions added to their care plan. Although staff documented falls and discussed interventions, these were not consistently reflected in the care plan as required. Staff interviews confirmed that nurses are responsible for updating care plans, but the process was not reliably followed.
The facility failed to obtain proper signatures for bed hold notices for four residents with severe cognitive impairments during hospital transfers. Verbal authorizations were documented, but no signatures were obtained, contrary to facility policy. Interviews with the DON and Administrator confirmed the expectation for correct completion of bed holds.
The facility failed to provide adequate bathing opportunities for four residents, as evidenced by clinical record reviews, resident interviews, staff interviews, and observations. A resident with moderate cognitive impairment reported receiving showers only once a week, despite requiring substantial assistance. Another resident with intact cognition also reported infrequent showers, and observations noted greasy and unclean hair. Two other residents, both with no cognitive impairment, were observed with disheveled and greasy hair, indicating a lack of recent bathing. The facility's policy emphasized cleanliness, but refusals were not adequately addressed by staff, leading to the deficiency.
The facility failed to employ a Certified Dietary Manager (CDM) for its food and nutrition service, impacting its compliance with staffing requirements. Interviews revealed that the facility had an interim manager working towards CDM certification, and a certified individual began training recently. The absence of a CDM prior to this and the lack of a policy for certified dietary managers were acknowledged by the facility's administration and consultant.
A facility failed to obtain or document attempts to obtain physical signatures on NOMNC forms for a resident. The resident's representative provided verbal consent, but the forms lacked the required signatures. CMS guidelines mandate in-person delivery and signature, or documented attempts if not possible. The administrator was unaware of the signature requirement, as Social Services handled the forms.
A resident with moderate cognitive impairment reported a missing quilt, which was not replaced by the facility. The inventory of personal property was incomplete, and staff interviews revealed that the inventory list was not updated as required by facility policy.
A facility failed to update a resident's care plan to include the use of high-risk opioid medication and its side effects. The resident, with moderate cognitive impairment and multiple diagnoses, was prescribed oxycodone-acetaminophen, which was not documented in the care plan. The facility's policy requires comprehensive care plans, which was not followed in this instance.
The facility failed to follow physician orders for daily weights for a resident with heart failure and for pressure ulcer dressing changes for another resident. The daily weights were not completed due to a broken scale, and there was no documentation of physician notification. Similarly, multiple dressing changes were missed without notifying the physician, contrary to facility policies.
Two residents with cognitive impairments eloped from an LTC facility due to inadequate supervision and malfunctioning door alarms. Despite being assessed as high risk for wandering, the residents managed to exit the facility, highlighting issues with the alarm system and staff response. Interviews revealed that staff were desensitized to frequent false alarms, delaying their response to actual incidents.
The facility failed to manage and document the use of psychotropic and opioid medications for two residents, leading to deficiencies in their care plans. A resident with COPD and respiratory failure was prescribed Zyprexa without specific targeted behaviors or non-pharmacological interventions documented. Another resident with coronary artery disease and fibromyalgia was prescribed multiple medications, including oxycodone and risperidone, without proper documentation of usage, side effects, or non-pharmacological interventions. The facility's policy on unnecessary drugs was not adhered to, as confirmed by the Administrator.
A facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) during incontinence care for a resident with an indwelling catheter. Two CNAs performed hand hygiene and donned gloves but did not wear gowns while repositioning the resident and completing peri care. The DON expected staff to follow EBP for residents with catheters, as outlined in the facility's policy on Standard and Transmission-Based Precautions.
The facility failed to provide meals in accordance with the dietary needs of three residents, serving meals that did not match their prescribed mechanical soft diets. Interviews revealed a lack of communication and training regarding dietary needs, with the dietary manager making menu changes without consulting the dietician. The facility's policy on therapeutic diets was not followed, leading to residents receiving incorrect meal textures, posing immediate jeopardy to their health and safety.
The facility failed to follow the planned menu for a lunch meal, serving a chicken wrap and lemon pudding instead of fried chicken and strawberry sponge shortcake. The Dietary Manager, new to her role and untrained, made substitutions without consulting the dietician, who was unaware of the changes. The facility's policy requires meals to meet nutritional needs, which was not adhered to in this instance.
The facility failed to serve food at safe temperatures, as observed during a meal service. Dietary trays were found with food temperatures below recommended levels, including fish sticks at 94.3°F, carrots at 93.5°F, and cheesy rice at 102°F. Additionally, pureed cheesy rice was served at 127°F, below the CDC's recommended reheating temperature of 165°F. The Administrator intervened to stop the service and educate the staff.
The facility failed to serve meals at regular times, as meals were consistently late by 15 to 30 minutes. Observations and interviews with residents and CNAs confirmed the delays, which varied depending on the day and the cook. The facility's policy required meals to be served at specific times, but this was not adhered to, causing dissatisfaction.
The facility failed to follow hand hygiene protocols during perineal care, dining service, and food preparation. A resident with severe cognitive impairment did not receive proper perineal care as CNAs did not perform hand hygiene after glove removal. Additionally, a CNA fed two residents without washing hands between them, and kitchen staff did not wash hands between glove changes. The facility's policies on hand hygiene were not adhered to, as confirmed by the ADON and Administrator.
A CNA failed to maintain the dignity of two residents during a dining experience by not communicating with them and improperly handling one resident's arm. The CNA placed a resident's arm across her chest without speaking to her while assisting another resident with eating. This action violated the facility's policy on resident rights, which emphasizes respect and recognition of residents' dignity.
The facility staff failed to ensure call light accessibility for two residents, leading to situations where a resident had to call the front desk for assistance and another felt fearful during a mechanical lift transfer. Despite the facility's policy requiring call lights to be within reach, staff frequently left them out of reach, impacting residents who were dependent on staff for personal hygiene and had no cognitive impairment.
A resident reported multiple incidents of improper use of a mechanical lift, including being banged on the lift, feeling insecure in a wheelchair, and experiencing fear when the emergency button was used during transfers. The facility's policy required two staff members for transfers, but the resident was transferred alone, and the lift was not hooked up correctly.
A resident with severe cognitive impairment and multiple diagnoses did not receive appropriate incontinence care, as two CNAs failed to follow the facility's perineal care policy. The resident was improperly positioned, and the CNAs did not maintain proper hand hygiene during the care process, which could contribute to urinary tract infections.
A facility failed to answer call lights within a reasonable time, affecting residents needing assistance. One resident experienced incontinence due to a delay, while another, requiring help due to hemiplegia, reported long wait times and overheard staff refusing assistance. A third resident reported frequent delays of up to 1.5 hours. Call light logs confirmed multiple instances of response times exceeding the facility's 15-minute policy.
The facility failed to provide meal alternatives or substitutions, as residents were limited to the daily menu or a few alternative options. A grievance highlighted weight loss concerns due to the removal of meal options, and interviews confirmed that residents could not request specific items not on the menu. The facility's policy aimed for a person-centered dining experience, but recent changes to the a la carte menu limited food availability to improve kitchen time management.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Administer Ordered Medications and Notify Physician of Missed Doses and Weight Change
Penalty
Summary
The facility failed to provide physician-ordered medications and failed to notify the physician when ordered medications were omitted for Resident #7, Resident #20, and Resident #35. Resident #7 had diagnoses including insomnia, depression, and Multiple Sclerosis, with a BIMS score of 9. The record showed multiple ordered medications, including omeprazole, fluvoxamine, melatonin, and FiberCon, were documented as not available or not found on separate occasions, and the EHR did not show physician notification for the omitted administrations. Resident #20 had diagnoses of anxiety disorder and depression with a BIMS score of 12. The physician orders included pantoprazole, lactulose, famotidine, and duloxetine. The progress notes documented pantoprazole as unavailable, lactulose as not available and later on order, famotidine as not available and reordered, and duloxetine as unavailable. The EHR did not indicate physician notification for the missed medications. Resident #35 had diagnoses of acute pain due to trauma, muscle spasm, and femur fracture, with a BIMS score of 11. The physician ordered lidocaine patches and sitagliptin phosphate, but the progress notes repeatedly documented the lidocaine patch as not available or no patches available, and sitagliptin phosphate as awaiting medication arrival. The EHR did not show physician notification for the omitted administrations. In addition, Resident #10 had a BIMS score of 9 and experienced significant weight fluctuations documented across the facility, hospital, and dialysis records. The facility’s records showed a physician order to notify the provider for signs or symptoms of fluid overload and weight gain, but the record did not show physician notification related to the weight change, and staff and the DON acknowledged the weight discrepancy and that the physician should have been notified.
Delayed Call Light Response Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by delayed responses to call lights for 3 of 16 residents reviewed. The report states the facility had a census of 57 residents and that residents, staff, and records documented repeated delays in answering call lights, including responses taking longer than 15 minutes and, in some instances, up to 45 minutes or about an hour. Resident #30 had a BIMS of 14 and diagnoses including dysphagia, hemiplegia and hemiparesis following cerebral infarction, and stiffness of the right shoulder. The resident required assistance with oral hygiene, toileting hygiene, dressing, and personal hygiene. The resident stated she could not find her call light one night, could not get help, and urinated on herself twice. She also stated that the prior week she sat on the toilet for 45 minutes waiting for help and timed the response on her phone. Resident #32 had a BIMS of 13 and required assistance with eating, oral hygiene, dressing, personal hygiene, and was dependent on staff for toileting hygiene, bathing, and footwear. The resident stated she sometimes waited longer than 30 minutes after using the call light when she needed to use the restroom and said the facility was severely understaffed. Resident #33 had a BIMS of 15 and required setup or clean-up assistance for several ADLs and partial/moderate assistance with lower body dressing and footwear. The resident stated staff frequently told her they were short on the floor, that there had been times when only one person was working on her hall, and that it could take up to an hour for her call light to be answered. The resident also stated that the prior night it took much longer than 15 minutes for staff to respond. Facility documents noted call light times in the grievance log and that resident council reported slower call light response. Staff interviews confirmed the staffing shortages, including one CNA on the overnight shift until after midnight on 3/8/26, with staff stating call lights were not answered within 15 minutes because there were not enough staff. The DON stated the expected staffing was 3 CNAs and 2 nurses on nights, acknowledged concerns with staffing and agency dependability, and acknowledged that the facility had grievances related to excessive call light times.
Food Served Below Required Temperature
Penalty
Summary
The facility failed to ensure that food served to residents was at proper temperatures. Resident #30, whose MDS documented a BIMS of 14 indicating no cognitive impairment, stated on 3/18/26 at 10:36 AM that dinner meals are served cool. Resident #30 said she does not ask staff to reheat the food because she just does not eat it, and stated staff would not reheat the food if she asked. Resident #33, whose MDS documented a BIMS of 15 indicating no cognitive impairment, stated on 3/18/26 at 7:58 AM that most meals are served cold, that she eats most meals in her room, and that she would like meals served warmer. She stated she would ask staff to warm the food, but it depends on which CNA is working whether they will do so. During observation on 3/19/26 at 12:11 PM, a room tray was delivered with a metal cover over the food and included enchilada, lettuce salad with dressing, apple crisp, and juice. Dietary staff checked the temperature of the enchilada and it read 129.6 degrees. The facility policy titled Checking Food Temperatures, revised 8/2018, stated meals will be served at appropriate temperatures and hot foods should be held at or above 135 degrees F. In interview on 3/25/2026 at 2:11 PM, the Administrator stated the food should be served at safe temperatures.
Hand Hygiene and EBP Not Followed During Medication Administration
Penalty
Summary
The facility failed to implement proper hand hygiene during medication administration for four residents observed receiving oral medications, insulin, and enteral tube medications. During observation, an LPN accessed medication records, prepared medications, and assisted a resident with oral medication ingestion, but did not perform hand hygiene immediately before or after medication administration before moving on to another resident. The same staff member then administered oral medications and insulin to another resident, performed hand hygiene only after entering the bathroom, and later continued medication preparation for a third resident without hand hygiene after handling soiled gloves and medication supplies. The facility also failed to follow Enhanced Barrier Precautions for a resident with a PEG tube. The resident’s MDS documented moderate cognitive impairment and feeding tube placement, and a sign outside the room indicated EBP requiring gown and gloves for direct resident care. During observed enteral medication administration, an LPN entered the room wearing gloves but no gown, handled the medication cart and computer, crushed and prepared medications, checked tube placement, flushed the tube, and administered medications through the PEG tube. Hand hygiene was not completed when entering or leaving the room or at the medication cart as described by the DON. The DON stated staff were required to perform hand hygiene immediately before and after medication administration for each resident and immediately before donning gloves and after doffing gloves. The DON also stated the resident with the PEG tube required EBP and that the nurse should have worn a gown during enteral tube medication administration. The Administrator stated she expected staff to follow infection control guidelines for hand hygiene.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
Failure to Provide Twice-Weekly Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance at least twice weekly, as required by its own policy, for two residents who were dependent on staff for bathing. For one resident with anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive impairment, the MDS documented total dependence on staff for bathing. Facility documentation showed that bathing was recorded as refused on one date, with actual baths provided on dates that resulted in a 6‑day interval without a bath on two separate occasions. The resident’s care plan indicated the resident was totally dependent on staff to provide a bath as necessary. For another resident with diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, facility records showed multiple dates where bathing was documented as refused or as not applicable. Review of the Follow Up Question Report demonstrated several extended gaps between baths: 6 days on two occasions, 7 days on one occasion, and 11 days on another, despite the facility policy requiring showers to be offered at least twice weekly and, if missed, to be offered on the next available day. In an interview, the DON stated that when a resident refuses a shower, staff are expected to continue to offer, try multiple times, try a different person, and continue to try the next day until the resident bathes, which was not reflected in the documented bathing intervals for these two residents.
Resident Funds Not Accessible at All Times
Penalty
Summary
The facility failed to provide access to personal funds managed by the facility or manage personal funds deposited at the facility for 2 of 3 residents reviewed, Resident #11 and Resident #30. Resident #11 had an MDS documenting a BIMS score of 10, indicating moderate cognitive impairment. Resident #30 had an MDS documenting a BIMS score of 14, indicating no cognitive impairment. During interview, Resident #30 stated she was unable to get her personal funds in the evening or on weekends, so she kept money in her purse to make sure she had money when she wanted it, and she said items had gone missing from her room, which worried her about keeping money there. Staff interviews and the Administrator’s statements showed the facility’s resident trust fund process depended on Staff A, the Social Services Director/Social Worker, who worked Monday through Friday from 8:00 AM to 4:30 PM and was the only staff member with a key to the petty cash box. Staff A stated residents could ask any staff member and she would get the money, but if money was needed in the evening or on the weekend, either she or the Administrator would have to come in to provide it. Staff B, a CNA, stated she did not know if residents could get their money at night or on the weekend, and Staff C, an LPN, stated she would have to call Staff A because she did not have access to resident money. The Administrator acknowledged residents with money in the resident trust did not have access to it 24 hours a day or 7 days a week and only had access when Staff A was at the facility. The facility policy stated resident funds managed by the facility are to be protected, with separate records maintained for each resident’s personal funds account and the Administrator responsible for informing residents of the policy and procedure governing resident funds.
Failure to Properly Complete Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to properly complete CMS form #10123 for 1 of 3 sampled residents, Resident #4, related to notice of Medicare/Medicaid coverage and potential liability for services not covered. The ABN form #10123 dated 12/23/25 showed the Social Worker documented that a 48-hour notice was waived. During interviews, the Social Worker stated she had completed the form and documented the waiver, but she could not recall the rationale for the waiver and later reported she was unable to locate documentation or rationale supporting it. The undated Advance Beneficiary Notice of Non Coverage Part A did not address form #10123 or the required 48-hour notice of Medicare Provider Non-Coverage. The form instructions stated that the NOMNC must be delivered at least two calendar days before Medicare-covered services end, or the second to last day of service if care is not being provided daily. The Social Worker stated that a 48-hour notice should not be documented as waived simply because the facility failed to provide the proper 48-hour advance notice. The DON reported she was not familiar with the requirements of ABNs, and the Administrator stated she was not fully educated regarding ABNs and expected the Social Worker to follow ABN guidelines.
Failure to Discontinue Ordered Antipsychotic Medication
Penalty
Summary
The facility failed to discontinue quetiapine after a physician order signed on 10/16/25 directed that the medication be stopped, and the antipsychotic continued to be administered to Resident #20 through October, November, and December 2025. Resident #20 had diagnoses of anxiety disorder and depression, and the MDS assessment documented a BIMS score of 12, indicating moderate cognitive impairment. Review of the October, November, and December MARs showed repeated administration of quetiapine after the discontinue order, with doses given daily in October and November and on multiple dates in December, despite the order to discontinue. Facility policy stated that each resident's drug regimen should be managed and monitored and that residents should receive only medications clinically indicated for their assessed conditions. The DON stated in interview that quetiapine should have been discontinued in October when the order was signed.
Missing discharge recapitulation of stay
Penalty
Summary
The facility failed to complete a recapitulation of stay after discharge for 2 of 3 residents reviewed for discharges, Resident #61 and Resident #63. Resident #61’s MDS documented diagnoses of hypertension, Bell’s Palsy, and prediabetes, with a BIMS score of 15 indicating no cognitive impairment. The census tab showed stop billing on 1/12/26, and the January 2026 notice to the Long Term Care Ombudsman showed the resident was discharged home on 1/12/26, but the medical record lacked a recapitulation of stay. Resident #63’s MDS documented diagnoses of hypertension, muscle weakness, and cardiac murmur, with a BIMS score of 14 indicating no cognitive impairment. The census tab showed stop billing on 1/15/26, and progress notes on 1/14/26 at 2:38 p.m. stated the resident would be returning to assisted living upon discharge from skilled services, but the medical record also lacked a recapitulation of stay. The facility’s Discharge Summary policy stated a discharge summary shall be prepared when a resident is expected to be discharged and include a recapitulation of the resident’s stay, and the DON stated that if it was not in the assessments then it was not completed.
PASRR Level II recommendations and updates not incorporated
Penalty
Summary
The facility failed to incorporate required PASRR Level II recommendations and failed to refer residents with newly evident or possible serious mental disorder or intellectual disability-related conditions for updated Level II evaluation for 3 of 4 residents reviewed. The report identified that the facility did not ensure PASRR-identified specialized or rehabilitative services were incorporated into care planning and delivered as required by the PASRR process. For one resident with diagnoses including major depressive disorder and schizophrenia, the PASRR Level II outcome required ongoing psychiatric medication management by a psychiatrist or psychiatric ARNP to evaluate response to psychotropic medications, modify medication orders, and assess the need for additional behavioral health services. Although the resident later received an order for clozapine and the care plan included psychiatric medication management, the record showed the psychiatric evaluation was delayed because of payment agreement and payee issues. Staff documented that attempts to arrange the evaluation were unsuccessful, that the resident became upset about paying out of pocket, and that no further attempts were made after the initial effort. For two other residents, the clinical records showed diagnoses that were not reflected in the existing PASRR documentation. One resident had anxiety disorder, depression, and hallucinations documented in the MDS and current diagnosis list, but the PASRR lacked those diagnoses and there was no updated PASRR. Another resident had schizophrenia documented in the MDS and current diagnosis list, but the PASRR listed psychotic delusional disorder instead and the record lacked an updated PASRR to include schizophrenia. The Social Worker stated the PASRR should have been updated to include the proper and all mental health diagnoses.
Failure to Update Care Plan After PASRR Level II Outcome
Penalty
Summary
The facility failed to revise Resident #4’s comprehensive care plan to include updated recommendations after a PASRR Level II Outcome was completed. Resident #4’s MDS documented a BIMS score of 9, indicating moderate cognitive impairment, along with diagnoses of major depressive disorder and schizophrenia. The EHR care plan reviewed on 3/18/26 contained service and support entries with future duration dates and discharge-related coordination language, but the record did not reflect timely incorporation of the updated PASRR information when it became available. A Notice of PASRR Level II Outcome dated 3/12/26 documented that Service Matters reviews completed on 1/28/26 and 3/9/26 found the nursing facility was not compliant because it had not developed the care plan according to state standards and/or had not incorporated PASRR-identified specialized and rehabilitative services. Staff A, the Social Service Director, stated she updated the care plans on 3/19/26 after receiving the updated PASRR on 3/12/26 and acknowledged the care plan should have been changed immediately. The DON stated she would have liked to see the care plans updated after the PASRR was completed in a timely manner, and the facility policy required the interdisciplinary team to develop and revise the comprehensive care plan to include PASRR recommendations and update it after each assessment.
Failure to Document and Provide Catheter Care
Penalty
Summary
Appropriate care was not provided for Resident #10, who had a BIMS score of 9 indicating moderate cognitive impairment and a diagnosis of neuropathic bladder. The resident also had a chronic indwelling Foley catheter placed during a hospital stay, with a urinary tract infection associated with the indwelling urethral catheter documented in the hospital discharge summary. The discharge summary noted the catheter had been changed prior to discharge and that care and management were to follow facility guidelines and protocol. Review of the resident’s EHR showed no care plan focus, goal, or interventions related to the catheter, no tasks related to catheter placement, and no MAR-TAR orders related to catheter care. Progress notes documented that the resident had a catheter after returning from the hospital and later still had the catheter, but staff acknowledged there were no orders, tasks, treatments, or cares documented for emptying, recording output, or cleaning the catheter after the resident returned from the hospital. Staff also acknowledged that the physician was not notified of the catheter upon return and that no care plan had been developed for it. The DON confirmed the absence of orders, care plan, tasks, and documented catheter care or output, and stated these should have been discussed with the resident and physician.
Improper PEG Tube Medication Administration
Penalty
Summary
The facility failed to implement its policies and procedures regarding the technical aspect of feeding tube administration for one resident with a PEG tube. During observation of the resident’s enteral medication administration, an LPN checked residual, completed an auscultation of air bolus for placement, flushed the tube with 30 cc of water, and then pushed water through the syringe with the palm of her hand. She drew up medications separately, pushed forcefully with the palm of her hand, and stated she had to use force because the syringe itself was difficult to push. She also flushed with 10 cc of water between medications, obtained a new syringe, obtained fresh water, crushed a medication, and later flushed with 30 cc and then 70 cc of water after administration. The resident’s care plan documented that the resident required bolus feeding through the PEG tube for nutrition and/or medication administration. The facility’s policy for gastrostomy tube care and management stated that medications should be administered via gravity or gentle pressure through a syringe, with the head of bed elevated to at least 30 degrees unless contraindicated, and the tube flushed with 15-30 mL of water before, between, and after medications. When interviewed, the DON stated she did not have any concerns with pushing the syringe piston.
Failure to Address Dementia Care in Care Plans
Penalty
Summary
The facility failed to address dementia care for 2 of 3 residents reviewed, including Resident #7 and Resident #28. Resident #7’s MDS documented diagnoses of Non-Alzheimer’s Dementia, Multiple Sclerosis, and cognitive communication deficit, with a BIMS score of 9 indicating moderate cognitive impairment. The resident’s active diagnosis list included dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. Review of the resident’s care plan with a revision date of 1/15/26 showed it lacked information regarding dementia care, despite the facility’s dementia care policy stating that person-centered care plans are to include and support dementia care needs identified in the comprehensive assessment. The DON stated during interview that dementia should be addressed on the care plan. Resident #28’s MDS documented a BIMS score of 7, indicating severe cognitive impairment, and listed a diagnosis of moderate vascular dementia with anxiety. The resident’s active diagnosis list also included moderate vascular dementia with anxiety. Review of the resident’s EHR care plan showed no individualized interventions related to the dementia diagnosis, including no verbal, behavioral, or environmental prompts to assist with completion of specific tasks or activities.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
Resident #16 was observed receiving insulin from Staff J, an LPN, who accessed the resident’s medication record, retrieved the insulin pen, attached the pen needle, and dialed the prescribed 10 units. Staff J did not perform the manufacturer-required safety test dose of 2 units before administering the insulin. The observation showed the insulin was then given to the resident in the right flank area. The facility’s Injections, Insulin policy last reviewed in July 2022 did not include information or instruction regarding use of an insulin pen. The manufacturer’s 2022 instructions required a safety test by dialing 2 units, holding the pen with the needle pointing up, tapping the reservoir to move air bubbles to the top, pressing the injection button to confirm insulin comes out, and repeating the test if needed. During interviews, the DON and Administrator stated that staff were expected to follow hand hygiene and manufacturer instructions for insulin pen administration, and the DON identified Staff J as an agency staff member.
Inaccurate Weight Documentation and Missing Follow-Up
Penalty
Summary
The facility failed to provide and maintain accurate resident records to correctly document weights for one resident. Resident #35 had diagnoses of heart failure, atrial fibrillation, and hypertension, and the MDS assessment documented a BIMS score of 11 indicating moderate cognitive impairment. The resident’s recorded weights showed major fluctuations, including 200 lbs on 1/9/26 from the hospital, 177.2 lbs on 1/18/26 by wheelchair, 176.0 lbs on 1/24/26 by mechanical lift, 259.5 lbs on 1/31/26 by wheelchair, 257.3 lbs on 2/1/26 by wheelchair, and 168.4 lbs on 3/1/26 by standing. The clinical record lacked documentation explaining these weight changes. During interview, the DON stated staff should have questioned the significant weight loss and gain entries, including the 1/18/26, 1/31/26, and 3/1/26 weights, and said there should have been follow-up or a re-weigh at those times.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program with a plan describing the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the annual survey and the previous annual survey conducted 3/11/25. The repeat deficiencies included F582 for Medicaid/Medicare Coverage/Liability notice, F584 for Safe/Clean/Comfortable/Homelike Environment, F677 for ADL Care provided for Dependent Residents, F684 for Quality of Care, and F880 for Infection Prevention & Control. Review of the facility policy titled QAPI, revised 10/2022, stated the purpose of the QAPI Plan and processes is to continually assess the facility's performance in all service areas so that systems and processes achieve the delivery of person-centered care and maximize the individual's highest practicable physical, mental, and social well-being.
QAA Meetings Lacked Trained Infection Preventionist Attendance
Penalty
Summary
The facility failed to have a trained Infection Preventionist present for its quarterly Quality Assessment and Assurance (QAA) meetings. Review of facility documentation titled QAPI attendance dated 12/18/2025 showed that a trained IP was not present at the meeting. The facility policy titled Quality Assessment Performance Improvement (QAPI), revised 10/2022, stated the committee would maintain a record of the dates of all meetings and the names and titles of those attending each meeting. During an interview on 3/26/2026 at 9:45 a.m., the Administrator stated there was no IP with training present from October 2025 until the current IP received training at the QAPI meetings. The facility reported a census of 57.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to update care plan interventions for a resident after multiple falls, as required by policy and regulatory standards. Record review showed that a resident with diagnoses of Alzheimer's disease, dementia, and malnutrition, and a BIMS score indicating severe cognitive impairment, experienced several falls over a period of time. Despite these incidents, the care plan did not reflect updated or new interventions to address the resident's fall risk. Incident reports documented each fall, but the care plan remained unchanged regarding fall prevention strategies. Interviews with staff, including an LPN and the DON, confirmed that nurses are responsible for entering interventions into the care plan after a fall. However, it was revealed that while interventions were sometimes documented in progress notes and discussed by the interdisciplinary team, they were not consistently incorporated into the resident's care plan. The DON acknowledged that the process for updating care plans was not always followed, particularly due to reliance on the MDS nurse to finalize interventions, and noted that a new MDS nurse was in training at the time.
Failure to Obtain Proper Bed Hold Signatures
Penalty
Summary
The facility failed to ensure that bed hold notices were properly signed by residents or their representatives when residents were transferred out of the facility. This deficiency was identified for four residents, all of whom had severe cognitive impairments as indicated by their BIMS scores. For Resident #4, the facility documented a verbal authorization from the resident's representative but did not obtain a signature. Similarly, Resident #11 was transferred to a hospital without a signed bed hold notice, and the documentation lacked a signature. Resident #40 was verbally informed about the bed hold, but the form was not signed. Resident #45's representative agreed to the bed hold via telephone, but no wet signature was obtained. Interviews with the Director of Nursing and the Administrator revealed that the facility's expectation was for bed holds to be completed and obtained correctly. The facility's policy, revised in May 2021, requires that residents or their representatives be informed in writing of their right to exercise the bed hold provision in the event of a transfer. However, the facility did not adhere to this policy, resulting in the deficiency. The facility reported a census of 50 residents at the time of the survey.
Failure to Provide Adequate Bathing Opportunities
Penalty
Summary
The facility failed to provide adequate bathing opportunities for four residents, as evidenced by clinical record reviews, resident interviews, staff interviews, and observations. Resident #46, with moderate cognitive impairment, reported receiving showers only once a week, despite requiring substantial assistance with bathing. The facility's records showed that Resident #46 had a shower on 2/16/25 and was marked as unavailable on 2/24/25. Similarly, Resident #202, with intact cognition, reported receiving showers only once a week, and observations noted greasy and unclean hair. The records indicated showers on 2/13/25 and 2/16/25, with a note of 'not applicable' on 2/24/25. Resident #2, with no cognitive impairment but suffering from depression, anxiety disorder, and chronic pain, was observed with disheveled and greasy hair, indicating a lack of recent bathing. The care plan required assistance with bathing twice weekly, but records showed refusals and 'not applicable' entries on several dates. Resident #37, also with no cognitive impairment, was observed with greasy hair and had a care plan requiring assistance with bathing twice weekly. Records showed refusals on multiple occasions, with only two full body baths completed over a month. The facility's policy emphasized promoting cleanliness and relaxation, but interviews revealed that refusals were not adequately addressed by staff, leading to the deficiency in providing necessary bathing care.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a clinically qualified nutrition professional, specifically a Certified Dietary Manager (CDM), which is a requirement for the food and nutrition service. The facility, with a census of 50 residents, did not have a CDM at the time of the survey. An interview with the Administrator on February 24, 2025, revealed that the facility had an interim manager who was working towards obtaining his CDM certification. By February 27, 2025, the Administrator confirmed that a person with CDM certification had started training that week, acknowledging that the facility did not have a CDM prior to this. Additionally, a facility consultant, Staff C, expressed the expectation for a certified dietary manager to be in charge of the kitchen and noted the absence of a policy for certified dietary managers at the facility.
Failure to Obtain Signatures on Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to obtain physical signatures or document attempts to obtain signatures on the Notice of Medicare Non-Coverage (NOMNC) forms CMS-10123 and CMS-10055 for a resident. The resident's representative gave verbal consent for the signature on the specified date, but the forms lacked the necessary physical signature from either the resident or their representative. Additionally, the resident's progress notes did not contain any documentation of attempts to obtain these signatures. The Centers for Medicare & Medicaid Services (CMS) guidelines require that NOMNC forms be delivered in person and signed by the beneficiary or their representative. If in-person delivery is not possible, alternative methods such as telephone, mail, or email can be used, but the facility must document these attempts and retain a copy of the unsigned notice while awaiting the signed version. The facility's administrator was unaware of the requirement for physical signatures, as the responsibility for these forms was delegated to Social Services.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property from loss or theft, specifically a quilt that went missing from the laundry. The resident, who has moderate cognitive impairment as indicated by a BIMS score of 12, reported the missing quilt to the facility, but it had not been replaced. An inventory document for the resident's personal property was found to be incomplete, with no items marked for personal inventory. Interviews with staff and the resident's representative revealed that the inventory form was not properly filled out at the time of admission, and the inventory list was not updated as required. The facility's policy mandates that an inventory of personal effects should be completed upon admission and updated as new items are brought in. However, this procedure was not followed, leading to the deficiency in protecting the resident's personal property.
Failure to Update Care Plan for Opioid Medication
Penalty
Summary
The facility failed to revise and update the care plan for a resident to include the usage of high-risk opioid medication and the side effects to monitor. The resident, who has diagnoses of coronary artery disease, fibromyalgia, and respiratory failure, was assessed with a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The Minimum Data Set (MDS) assessment and the Order Summary Report revealed an order for oxycodone-acetaminophen, an opioid medication, which was not reflected in the resident's care plan. The facility's policy on Comprehensive Person-Centered Care Planning mandates the development of a comprehensive care plan for each resident, which was not adhered to in this case. An interview with the Administrator confirmed that the medication and its side effects should have been included in the care plan.
Failure to Follow Physician Orders for Daily Weights and Dressing Changes
Penalty
Summary
The facility failed to provide physician-ordered daily weights for a resident with heart failure, hypertension, and coronary artery disease, who had a severe cognitive impairment. Despite a physician's order for daily weights to monitor potential weight gain, the facility's records showed repeated entries indicating that the scale was broken or unavailable over several months. There was no documentation that the physician was notified about the inability to complete the daily weights as ordered, which is a deviation from the facility's policy to accurately implement physician orders. Additionally, the facility did not adhere to physician orders for pressure ulcer dressing changes for another resident with hypertension, anxiety disorder, and edema, who had no cognitive impairment. The resident reported having a sore that required dressing changes twice a day. However, the Treatment Administration Record (TAR) lacked documentation of dressing changes on multiple occasions across three months. The clinical record did not show any notification to the physician about the missed dressing changes, contrary to the facility's wound management policy, which requires necessary treatment and services to promote healing and prevent infection.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate nursing supervision for two residents, leading to incidents of elopement. Resident #22, who had a history of non-traumatic brain dysfunction and Alzheimer's disease, was found outside the facility on two occasions. The resident had previously been assessed as a high risk for wandering, with scores indicating significant risk. Despite these assessments, the resident managed to exit the facility through a hallway into the assisted living portion and was later found in the parking lot. Resident #48, diagnosed with non-traumatic brain dysfunction, bipolar disorder, and non-Alzheimer's dementia, also eloped from the facility. The resident was found returning through the front doors with multiple items of clothing, indicating they had been outside. The door alarms had sounded, but staff interviews revealed that the alarms were not functioning correctly, often going off without being triggered by an actual event. This malfunction led to staff becoming desensitized to the alarms, delaying their response to actual elopement incidents. Interviews with various staff members, including CNAs, the ADON, and the maintenance supervisor, highlighted issues with the door alarm system. The alarms were reported to have been malfunctioning, causing confusion and delayed responses from the staff. The previous administrator was aware of the issues but did not ensure timely repairs, contributing to the residents' ability to elope. The facility's policy on elopement and unsafe wandering emphasized the need for a safe environment and adequate supervision, which was not effectively implemented in these cases.
Deficiencies in Medication Management and Care Planning
Penalty
Summary
The facility failed to properly manage and document the use of psychotropic and opioid medications for two residents, leading to deficiencies in their care plans. Resident #4, who has diagnoses of chronic obstructive pulmonary disease, respiratory failure, and dependence on supplemental oxygen, was prescribed Zyprexa, an antipsychotic medication. However, the resident's care plan lacked specific targeted behaviors for the use of this medication and did not include non-pharmacological interventions to be tried prior to or alongside the medication. This oversight indicates a failure to adhere to the facility's policy on unnecessary drugs, which requires the incorporation of medication-related goals and parameters into the comprehensive care plan. Similarly, Resident #13, with diagnoses of coronary artery disease, fibromyalgia, and respiratory failure, was prescribed multiple medications, including oxycodone, risperidone, and sertraline. The care plan for this resident also lacked information on the usage, side effects, and non-pharmacological interventions for these medications. Additionally, it did not specify the targeted behaviors for the antipsychotic and antidepressant medications. The facility's policy emphasizes the importance of managing and monitoring each resident's medication regimen to promote their highest practicable well-being, which was not followed in these cases. An interview with the Administrator confirmed the expectation that care plans should include side effects, targeted behaviors, and non-pharmacological interventions.
Failure to Implement Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) during incontinence care for Resident #45, who was one of three residents reviewed for infection control. Resident #45 had an indwelling catheter and was diagnosed with neurogenic bladder and hemiplegia following a cerebral infarction. During an observation, two Certified Nursing Assistants (CNAs), Staff A and Staff B, performed hand hygiene and donned gloves before repositioning Resident #45 and completing peri care. However, neither staff member donned a gown while performing these tasks. The Director of Nursing (DON) stated that the expectation was for staff to follow EBP when caring for residents with catheters. The facility's policy on Standard and Transmission-Based Precautions, revised in March 2024, indicated that EBP should be used in conjunction with standard precautions, including the use of gowns and gloves during high-contact resident care activities to prevent the indirect transfer of Multi-Drug Resistant Organisms (MDROs).
Failure to Provide Appropriate Diets for Residents
Penalty
Summary
The facility failed to provide meals in accordance with the dietary needs of three residents, as observed during a meal service. Residents were served meals that did not match their prescribed mechanical soft diets, which require specific textures to accommodate their dietary restrictions. For instance, one resident received a chicken wrap with lettuce and potato chips, which are not suitable for a mechanical soft diet. Another resident was served a similar meal and began eating potato chips, which were also inappropriate for their dietary needs. These observations indicate a failure to adhere to the residents' dietary orders, which are crucial for their health and safety. Interviews with staff revealed a lack of communication and training regarding dietary needs and meal preparation. The dietary manager admitted to making menu changes without consulting the dietician, resulting in inappropriate meal textures being served. Additionally, the dietary manager had only been in her position for a short time and had not received adequate training. Staff interviews further highlighted ongoing issues with serving incorrect food textures and liquids, with CNAs often having to intervene to correct these errors before residents consumed the meals. The facility's policy on therapeutic diets mandates that diets must be prescribed by the attending physician and that a tray identification system should ensure residents receive the correct diet. However, the failure to follow these protocols led to residents receiving meals that did not meet their dietary requirements. This deficiency was identified as an immediate jeopardy to the health and safety of the residents, as the incorrect meal textures could pose significant risks to their well-being.
Failure to Follow Planned Menu and Consult Dietician
Penalty
Summary
The facility failed to adhere to the planned menu for residents, as observed during a lunch meal service. The planned menu for the lunch meal included fried chicken, potato salad, green beans with bacon, strawberry sponge shortcake, and milk. However, the meal served consisted of a chicken wrap, potato salad, potato chips, and lemon pudding. This deviation from the planned menu was due to the Dietary Manager, Staff C, not ordering enough fried chicken and only receiving one spongecake, leading her to make substitutions without consulting the dietician. Staff C, who had been in her position for only a week and a half, admitted to not having received training as a dietary manager and did not maintain a log of substitutions at the facility. The dietician, Staff D, confirmed that she was not contacted for any menu changes and emphasized the importance of appropriate nutritional exchanges for substitutions. The facility's policy on dining and meal service, last updated in 2019, states that meals should be nourishing, palatable, and meet the nutritional and special dietary needs of residents. The Administrator expected the residents to receive the planned menu, highlighting a failure in communication and adherence to established protocols.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at a proper temperature, as observed during a meal service. During an observation, three dietary trays were noted sitting on a table with covers on. The Dietary Manager, identified as Staff C, was asked to take meal temperatures before the trays were sent to residents. The temperatures recorded were 94.3 degrees Fahrenheit for fish sticks, 93.5 degrees Fahrenheit for carrots, and 102 degrees Fahrenheit for cheesy rice, all of which were below the recommended safe temperature. Staff C left the cover off the meal tray, and approximately 10 minutes later, it was revealed that the room tray needed to be remade. Additionally, a tray with pureed food was observed at the service window. Staff C confirmed that the food was pureed cheesy rice, which had just been microwaved. Upon checking, the temperature of the pureed cheesy rice was found to be 127 degrees Fahrenheit, which is below the recommended reheating temperature of 165 degrees Fahrenheit as per the Center for Disease Control guidelines. Despite this, Staff C covered the bowl and placed it in the service window, indicating it was ready to be served. The Administrator intervened and educated Staff C that the meal was not hot enough to serve.
Facility Fails to Serve Meals on Time
Penalty
Summary
The facility failed to provide meals at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Observations and interviews revealed that meals were consistently served late. On 7/25/24, the first meal was served at 12:23 p.m., and the last meal was served at 1:25 p.m., which was later than the scheduled lunch time of 12:00 p.m. as per the facility's policy. Interviews with residents and staff confirmed that meals were typically served 15 to 30 minutes late, depending on the day and who was cooking. The facility's policy, updated in November 2019, stated that meals should be served at specific times: breakfast at 7:30 a.m., lunch at 12:00 p.m., and dinner at 5:00 p.m. The Administrator expected the lunch meal to be served at noon, but this expectation was not met, leading to dissatisfaction among residents and staff.
Failure to Follow Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during perineal care for a resident with severe cognitive impairment and total dependence on staff for personal hygiene. During an observation, two CNAs were seen providing perineal care to the resident without following the facility's policy, which required the resident to be positioned on her back for proper access. The CNAs did not perform hand hygiene after removing soiled gloves and before touching other surfaces, such as the resident's blankets and pillows, or before repositioning the resident. This failure to follow proper hand hygiene procedures was confirmed by the Assistant Director of Nursing, who stated that staff should adhere to the policy. Additionally, the facility did not ensure proper hand hygiene during dining service and food preparation. A CNA was observed feeding two residents consecutively without performing hand hygiene between assisting each resident. In the kitchen, the Dietary Manager and another staff member were seen changing gloves multiple times without washing their hands after each glove removal, contrary to the facility's hand washing policy. The Administrator confirmed that staff were expected to wash their hands after removing gloves and between assisting residents.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to uphold the dignity of residents during a dining experience, as observed on 7/25/24. A Certified Nursing Assistant (CNA), identified as Staff H, was seen feeding two residents simultaneously. During this process, Resident #17 attempted to sit forward in her wheelchair, at which point Staff H placed the resident's left arm across her chest without any verbal communication. Staff H continued to assist Resident #18 with eating, providing three more bites of food before addressing Resident #17. Staff H then left the table briefly, asking another staff member to watch Resident #17, and upon returning, resumed feeding both residents without speaking to them. This action was contrary to the facility's policy on resident rights, which emphasizes treating residents with consideration, respect, and recognition of their dignity and individuality. An interview with the Administrator on 7/28/24 confirmed that the staff should have engaged in communication with the residents and should not have placed an arm across Resident #17's chest. The facility's policy, reviewed in June 2023, clearly states the importance of respecting residents' dignity and individuality, which was not adhered to in this instance.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility staff failed to provide reasonable accommodation of needs by not placing the call light within reach of residents for two out of six residents reviewed. Resident #1 reported that the call light was left out of reach after care, requiring the resident to call the front desk for assistance. Additionally, during a mechanical lift transfer, the nurse left Resident #1 unattended and without a call light, causing the resident to feel fearful of falling. Resident #6, who had no cognitive impairment and was dependent on staff for personal hygiene, also reported that staff frequently failed to place the call light within reach, necessitating calls to the facility for help. The facility's Call Light policy, last revised in May 2007, requires staff to leave the call device within the resident's reach before leaving the room.
Improper Use of Mechanical Lift Leads to Resident Safety Concerns
Penalty
Summary
The facility failed to use the mechanical lift appropriately, leading to potential hazards and accidents for a resident. The resident reported that during a transfer, her foot was banged on the mechanical lift, and she was placed incorrectly in her wheelchair, causing her to feel as though she might slip out. Additionally, the resident was left unattended without a call light while the nurse went to get help. The resident also experienced fear when staff used the emergency button to lower her into bed, which released quickly and startled her. Further incidents involved the use of the emergency button by CNAs during transfers, which was not in accordance with the facility's mechanical lift policy. The policy required the use of two healthcare personnel during transfers, with one operating the lift and the other assisting. However, the resident reported being transferred alone by a CNA, and the lift was not hooked up correctly, necessitating intervention by another CNA. These actions were contrary to the facility's policy and contributed to the deficiency.
Inadequate Incontinence Care and Hand Hygiene
Penalty
Summary
The facility failed to provide complete and appropriate incontinence care to prevent urinary tract infections for a resident with severe cognitive impairment and multiple diagnoses, including non-traumatic brain dysfunction, dementia, and dysphagia. The resident was totally dependent on staff for toileting hygiene, showering, and personal hygiene. During an observation, two CNAs were seen providing perineal care to the resident in a manner that did not align with the facility's policy. The resident was positioned on her side, which did not allow proper physical and visual access to the perineal area, and the CNAs did not follow the correct sequence of cleansing as outlined in the facility's perineal care policy. Additionally, the CNAs failed to maintain proper hand hygiene during the care process. After removing soiled gloves, one CNA placed them on the bed and touched her scrub pants before performing hand hygiene. The other CNA did not perform hand hygiene after discarding used wipes and gloves and proceeded to handle the resident's blankets, pillows, and wet wipe package. These actions were inconsistent with the facility's policy, which emphasized the importance of hand hygiene and proper positioning during perineal care. The Assistant Director of Nursing confirmed that staff should follow the policy when performing perineal care and hand hygiene.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to consistently answer call lights within a reasonable amount of time, as evidenced by reports from residents and staff interviews. Resident #1 experienced a significant delay in call light response, resulting in incontinence. The grievance resolution form indicated that the call light was activated at 6:30 AM and not answered until 7:30 AM. Resident #8, who requires substantial assistance for personal hygiene due to hemiplegia and an overactive bladder, reported that staff failed to assist her to the bathroom every two hours as needed. She also mentioned overhearing a staff member refusing to help her, leading her to attempt to use the bathroom independently, which resulted in an accident. Resident #15, who requires partial to moderate assistance with toileting hygiene, reported call light response times ranging from 40 minutes to 1.5 hours, occurring five times a week. The call light logs for both Resident #8 and Resident #15 showed multiple instances of response times exceeding the facility's policy of 15 minutes. Staff interviews revealed that call lights were often answered after 15 minutes, depending on the staff on duty, and that nurses and office staff were supposed to assist if CNAs were unable to respond promptly, but often did not.
Failure to Provide Meal Alternatives
Penalty
Summary
The facility failed to provide meal alternatives or substitutions to residents, as observed through resident and staff interviews and a review of facility policies. A grievance filed on April 1, 2024, highlighted concerns about weight loss among residents due to the removal of meal options, with residents being told they could not have items not listed on the menu, such as toast, yogurt, applesauce, pudding, and eggs. Another grievance on June 14, 2024, involved a resident who requested an egg sandwich for breakfast but was denied because it was not on the menu. Interviews with staff and residents confirmed that residents were limited to choosing from the daily menu or a few alternative options, such as deli sandwiches, grilled cheese, and chicken noodle soup. The facility's policy on dining and meal service, last updated in November 2019, stated that the dining experience should be person-centered and supportive of individual needs, providing nourishing and attractive meals that meet nutritional and special dietary needs. However, the administrator revealed that the facility had recently changed the a la carte menu to improve time management in the kitchen, limiting the availability of certain items. This change resulted in residents being unable to request specific food items, such as different types of eggs, unless specifically requested, which was not an option prior to the surveyor's inquiry.
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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