Holy Spirit Retirement Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux City, Iowa.
- Location
- 1701 West 25th Street, Sioux City, Iowa 51103
- CMS Provider Number
- 165266
- Inspections on file
- 20
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Holy Spirit Retirement Home during CMS and state inspections, most recent first.
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.
The facility did not properly document vaccine refusals in the medical records for several residents with various chronic conditions. Although the electronic health record immunization section showed that vaccines were refused, there were no corresponding entries in the progress notes, and declination forms were not obtained as required by facility policy. Interviews with the DON and Administrator confirmed that refusals were not consistently documented.
Four residents with documented needs for restorative care did not consistently receive or have restorative services documented, despite care plans indicating such interventions were necessary to maintain ADLs. Residents and family members reported infrequent or absent restorative care, and staff interviews revealed that the restorative aide was often reassigned to other duties due to staffing shortages, resulting in restorative care not being performed as required by facility policy.
Staff did not follow the planned menu for a lunch meal, omitting bread and margarine that were listed and selected by residents, including those on pureed diets. Observations and staff interviews confirmed that these items were not prepared or served as required by facility policy.
The facility did not ensure the Medical Director attended required quarterly QAA meetings, as evidenced by missing signatures on meeting minutes and confirmation from the DON. Facility policy specifies the Medical Director must participate in these meetings.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice, but staff failed to update the care plan to include hospice services. Despite documentation confirming hospice admission and ongoing services, the care plan did not reflect this change, contrary to facility policy and expectations.
Two residents who were dependent on staff for ADL support did not receive adequate care, including timely toileting, proper positioning in wheelchairs, and correct management of an indwelling Foley catheter. One resident was left in a urine-saturated brief and without required leg support, while another had a catheter bag improperly placed above the bladder, contrary to care plans and facility policy. Staff interviews and observations confirmed lapses in following required care procedures.
A resident with severe cognitive deficits and total dependence on staff for care was found with an unexplained bruise under her eye. Staff could not determine how the injury occurred, despite the resident's care plan indicating a need for close supervision and specific interventions. The incident was discovered by an LPN, and neither the overnight nurse nor CNA were aware of any event leading to the injury.
Two residents with sleep apnea and respiratory conditions did not have current CPAP settings available to staff, and their CPAP masks and tubing were not monitored or replaced according to policy or supplier schedules. Both residents used visibly worn equipment for extended periods, and neither clinical orders nor care plans included the required settings. Staff interviews confirmed a lack of awareness and procedures for CPAP supply maintenance.
A resident with COPD and other conditions did not receive proper staff support for CPAP use, as no trained personnel were available to monitor or adjust the device. The receptionist, rather than clinical staff, assisted with the CPAP on two occasions due to lack of staff knowledge, and the DON confirmed the absence of trained staff or a respiratory therapist to oversee CPAP settings.
Staff did not follow hand hygiene protocols during incontinence care for a dependent resident with multiple medical conditions. CNAs changed gloves without using hand sanitizer and left the room without washing their hands, despite facility policies requiring proper hand hygiene to prevent infection.
The facility failed to implement proper infection prevention practices, including hand hygiene and enhanced barrier precautions, during care for residents with medical devices. Staff were observed not following hand hygiene protocols, and no enhanced barrier precautions were in place for residents with feeding tubes and catheters. Additionally, the facility lacked documented COVID-19 vaccination policies, despite claiming to follow CDC guidelines.
The facility did not conduct the required Iowa Criminal Background check and dependent adult/child abuse registry check for a CNA before employment. The facility's policy exempted staff under a certain age from these checks, contrary to federal regulations. The Administrator was aware of the federal requirements but not the facility's non-compliant policy.
The facility failed to provide food in the correct consistency for residents on mechanically altered diets. During a lunch service, four residents with dietary needs were served coleslaw instead of the steamed cabbage listed on the menu. Staff F, a Dietary Aide, admitted to the oversight. The facility's policy requires meals to be checked against the therapeutic diet spreadsheet, but this was not followed, as confirmed by the Certified Dietary Manager and Registered Dietitian.
The facility failed to maintain proper food handling and sanitation practices, affecting 61 residents. During a lunch service, a dietary aide did not perform hand hygiene between tasks and handled hamburger buns directly with their hands instead of using tongs. This was contrary to the facility's hand washing policy, which requires hand hygiene to prevent cross-contamination. The Certified Dietary Manager confirmed the improper handling of food.
A resident with severe cognitive impairment was left with food debris on their clothing protector and face after a meal, which was not cleaned up by staff in a timely manner. The resident's family member later addressed the issue, highlighting a failure to adhere to the facility's dignity policy.
A facility failed to refer a resident for a Level II PASRR evaluation after the resident was diagnosed with major depressive disorder and psychotic disorder. Despite these new diagnoses, the facility did not resubmit the PASRR for further evaluation, as required by their policy. The oversight was confirmed by the DON, who expected the social worker to handle the resubmission.
A facility failed to follow a care plan requiring supervision for a resident with moderate cognitive impairment and a high risk of falls. Despite the care plan's directive, the resident was observed unattended in a wheelchair multiple times. Staff interviews revealed a lack of awareness of the supervision needs, and the DON acknowledged the care plan did not reflect the requirement.
A facility failed to follow its policies for feeding tube management for a resident with no cognitive impairment. The staff did not accurately measure the prescribed 330 mL of supplemental formula, instead 'eyeing' the amount to just above 300 mL. Additionally, medications were pushed with a piston syringe rather than administered by gravity flow, contrary to facility expectations. The DON confirmed these actions were not in line with the facility's procedures.
A facility failed to store medications properly, as a bottle of Tums was found in a resident's room on two occasions. The resident's records lacked an assessment for self-administration of medications, and the DON confirmed the resident was not able to self-administer. The facility's policy requires adherence to professional standards, which was not followed.
A resident with COPD was observed using oxygen, but the facility failed to maintain accurate EHR documentation. The resident's care plan included oxygen therapy, yet the most recent order was discontinued months prior, and no current order was found in the MAR or TAR. The DON acknowledged the oversight, noting the order might have been missed after a hospital stay.
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 Document Vaccine Refusals in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented electronic health records for four out of five residents reviewed. Specifically, for multiple residents with various diagnoses including heart failure, peripheral vascular disease, renal insufficiency, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, and respiratory failure, the electronic health record immunization section indicated that these residents refused vaccines such as the Covid-19, influenza, and pneumococcal vaccines. However, there were no corresponding entries in the progress notes documenting these refusals, as required by facility policy. Interviews with the DON revealed that declination forms were not obtained when residents refused vaccines, and documentation was only made if a vaccine was accepted. The DON stated that for residents with lower cognitive scores or a medical POA, the POA would be contacted, and refusals by POA would be documented in the progress notes. The Administrator confirmed that refusals should be charted in the medical record with a signed declination form. Facility policy also required that vaccine refusals be documented in the resident's medical record, which was not done in these cases.
Failure to Provide and Document Restorative Care for Residents
Penalty
Summary
The facility failed to provide and document restorative care for four residents who were identified as needing such services to maintain their activities of daily living (ADLs). Each resident had documented diagnoses such as muscle wasting, weakness, unsteadiness, repeated falls, or stroke, and their care plans included restorative programs to maintain or improve their functional abilities. Despite these documented needs and care plans, restorative care was either not provided as scheduled or was provided infrequently, as evidenced by restorative care flow records and weekly reviews showing little to no restorative care delivered over a 15-day period. Resident interviews confirmed the lack of restorative care, with residents reporting that they only received therapy or restorative interventions once or twice a week, or not at all. Some residents expressed concern about the potential for loss of function due to the lack of regular restorative therapy. Family members also voiced dissatisfaction, noting that the restorative program was not being implemented as expected and expressing concern about the residents' declining abilities. Staff interviews revealed that the restorative aide was frequently reassigned to direct resident care due to staffing shortages, preventing her from performing restorative duties. The DON acknowledged that restorative care was not consistently provided, attributing this to staff turnover and the need to reallocate the restorative aide to cover other care needs. The facility's own policy required that residents receive restorative nursing care as needed to promote optimal safety and independence, but this was not followed for the residents reviewed.
Failure to Serve Menu Items as Planned
Penalty
Summary
Facility staff failed to follow the planned menu for residents, as evidenced by observations and menu reviews. On the specified lunch meal, the planned menu included turkey tetrazzini, buttered peas, bread and margarine, fruited gelatin, and milk. However, during the puree process and meal service, bread and margarine were not pureed or served, despite being listed on the menu and selected by residents as a meal choice. Observations confirmed that no bread and margarine were provided to residents, including those on pureed diets. Staff interviews with the Dietary Manager and Dietician confirmed that bread and margarine should have been served according to the menu and resident selections. Facility policy requires that meals be served as listed on the menu and checked against therapeutic diet spreadsheets, which was not followed in this instance.
Medical Director Absent from Required QAA Meetings
Penalty
Summary
The facility failed to ensure that the Medical Director attended the quarterly Quality Assessment and Assurance (QAA) meetings as required. Review of the Quality Assurance Performance and Improvement Meeting Minutes for a meeting dated 11/13/24 showed that the Medical Director's signature was missing, indicating their absence. The facility's own policy, dated March 2020, specifies that the Medical Director is a required member of the QAA committee, which must meet at least quarterly. During an interview, the Director of Nursing confirmed that the Medical Director should be present at these quarterly meetings. The facility reported a census of 61 residents at the time of the review.
Failure to Update Care Plan for Hospice Admission
Penalty
Summary
The facility failed to update the care plan for one resident after the initiation of hospice services. Specifically, a resident with severe cognitive deficits, total dependence for activities of daily living, and multiple diagnoses including diabetes mellitus, Alzheimer's disease, cerebrovascular accident with hemiplegia, and oral dysphagia, was admitted to hospice on 4/16/25. Despite this significant change in care needs, the resident's care plan, last updated on 4/8/25, did not include a focus area for hospice services, even though documentation confirmed hospice admission and services had begun. Observations and interviews confirmed the resident was receiving hospice care, and the DON stated that hospice should be added to the care plan as soon as a resident is admitted to hospice. Facility policy requires that comprehensive, person-centered care plans include all services necessary to meet the resident's needs, but this was not followed in this case, resulting in the omission of hospice from the care plan.
Failure to Provide Adequate ADL Assistance and Catheter Care
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents who were dependent on staff for care. One resident, who had severe cognitive deficits, post-polio syndrome, and was non-ambulatory, was observed multiple times in a wheelchair with her feet dangling unsupported and without a padded footrest as directed in her care plan. She was also found sitting in a urine-saturated brief, and during a transfer with a mechanical lift, urine spilled from her clothing and pooled in the wheelchair and on the floor. Staff interviews revealed that this resident was routinely awakened and transferred to her wheelchair before 6:00 AM, often left to sleep in the chair, and not always provided with timely toileting or repositioning as required by her care plan and facility policy. Another resident, who had moderate cognitive deficits and an indwelling Foley catheter, was found in bed with the catheter drainage bag hanging on the bedrail above the level of his bladder, contrary to infection control guidelines and facility policy. Nursing notes indicated that this resident had experienced issues with catheter blockage, cloudy urine, and was treated for a urinary tract infection. Staff acknowledged that the catheter bag should be kept below the bladder to prevent backflow and potential infection, but this was not done during the observation. Facility policies required incontinent residents to be checked and changed every two hours and for catheter care to be provided every shift. Despite these policies, direct observations and staff interviews confirmed that care was not consistently provided as required, resulting in residents being left in soiled briefs, improperly positioned, and with improper catheter management.
Failure to Adequately Supervise Resident to Prevent Injury
Penalty
Summary
A deficiency occurred when the facility failed to adequately supervise a vulnerable resident to prevent injury. The resident, who had severe cognitive deficits, was totally dependent on staff for dressing, toileting, and transfers, and required two staff members and a mechanical lift for transfers. She was observed with a large bruise under her right eye, which staff could not fully explain. The resident was unable to communicate how the injury occurred due to her cognitive condition. Staff hypothesized about possible causes, including accidental contact with the mechanical lift or her glasses, but no definitive cause was identified. The incident was first noticed by an LPN while the resident was in her wheelchair in the dining room, and neither the overnight nurse nor CNA on duty at the time were aware of any accident or incident that could have caused the bruise. The resident's care plan indicated she was at risk for falls and required staff to anticipate and meet her needs, including the use of a padded foot rest and regular toileting assistance. Despite these interventions, the facility was unable to determine how the injury occurred, and there was no documentation or witness to an event that could explain the bruise. The facility's policy required evaluation of injuries of unknown source and changes to the care plan to prevent recurrence, but the lack of supervision or failure to identify the cause of the injury led to the deficiency.
Failure to Maintain and Monitor CPAP Equipment and Settings
Penalty
Summary
The facility failed to provide staff with current CPAP machine settings and did not monitor or maintain CPAP mask and tubing needs for two residents. For one resident with diagnoses including COPD, CAD, and renal insufficiency, observations revealed that the CPAP machine was present at the bedside, but the resident had been using the same mask and tubing since admission, which were visibly worn and misshaped. The resident was unaware of the CPAP settings, and neither the clinical physician orders nor the care plan included the required CPAP settings. Chart review confirmed the absence of documentation regarding CPAP settings or supply changes, and the equipment supplier reported no supplies had been ordered since 2019. For another resident with COPD, insomnia, and renal insufficiency, similar deficiencies were observed. The resident and a family member reported that the same CPAP mask and tubing had been used for over a year, and the family member had to take the machine to the supplier to verify settings due to uncertainty about possible changes. The clinical orders and care plan also lacked CPAP settings, and there was no documentation of supply changes. The equipment supplier confirmed that no supplies had been ordered since the previous year, despite an established replacement schedule. Interviews with facility staff, including the DON, revealed a lack of awareness and procedures regarding the maintenance and replacement of CPAP supplies. The DON acknowledged that the facility is responsible for maintaining CPAP machines and that settings should be available to staff, but admitted to not having considered the supply replacement process. The facility's own policy requires physician orders to specify CPAP settings and mandates regular cleaning and replacement of equipment, which was not followed in these cases.
Failure to Train Staff on CPAP Use and Maintenance
Penalty
Summary
Staff failed to maintain and monitor CPAP settings for a resident diagnosed with COPD, insomnia, and renal insufficiency, who used a non-invasive mechanical ventilator. The resident's CPAP machine was observed on the bedside table, and a family member reported concerns that staff were not knowledgeable about the device, leading her to take the machine to the home supplier to verify its settings. The family member also stated that no staff assisted with the CPAP, and that the receptionist, rather than clinical staff, had to help with the device on two occasions because no one else knew how to operate it. Interviews confirmed that the receptionist assisted the resident with the CPAP due to a lack of trained staff, and the DON acknowledged that the facility did not have staff trained in CPAP use or a respiratory therapist available for consultation. The DON stated that only a respiratory therapist should monitor CPAP settings, but the facility did not have one accessible, resulting in unqualified personnel providing assistance with the resident's CPAP machine.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Staff failed to follow appropriate hand hygiene protocols during incontinence care for a resident with severe cognitive deficits, total dependence for activities of daily living, and multiple complex medical conditions including post-polio syndrome, intracerebral hemorrhage, type 2 diabetes, and chronic kidney disease. On two separate occasions, certified nurse aides (CNAs) provided care to the resident after an episode of incontinence, including transferring her using a mechanical lift and changing soiled clothing and linens. During these cares, staff removed soiled gloves and either failed to wash their hands or did not use hand sanitizer between glove changes. In both instances, staff left the resident's room without performing required hand hygiene. Facility policies required staff to wear gloves when in contact with blood, body fluids, or excretions, and to discard gloves after a single use. The hand hygiene policy mandated that all personnel follow handwashing procedures to prevent the spread of infection. Despite these policies, direct observation and interviews confirmed that staff did not consistently adhere to hand hygiene protocols during resident care, resulting in a failure to implement the facility's infection prevention and control program.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement appropriate infection prevention practices, as evidenced by multiple observations and interviews. Staff E, an LPN, was observed not performing hand hygiene before entering a resident's room and during the administration of enteral feeding. The staff member did not follow the facility's hand hygiene policy, which requires hand hygiene before and after direct resident contact and glove use. Additionally, no enhanced barrier precautions were in place during the care of Resident #24, who had a feeding tube, and no gown was donned during the procedure. In another instance, Staff J, Staff K, and Staff L were observed performing catheter and peri care on Resident #44 without using enhanced barrier precautions or gowns, despite the resident having a suprapubic catheter. Although hand hygiene was performed, the lack of enhanced barrier precautions was noted. The facility's failure to implement these precautions was confirmed through interviews with staff, who indicated that no residents were currently on enhanced barrier precautions, despite the presence of indwelling medical devices. Furthermore, the facility lacked written policies related to COVID-19 vaccinations, as revealed during an interview with the Director of Nursing. The facility claimed to follow CDC guidelines but did not have these guidelines documented. This lack of documentation and adherence to infection prevention protocols, including enhanced barrier precautions for residents with indwelling medical devices, contributed to the deficiencies identified during the survey.
Failure to Conduct Required Background Checks for Staff
Penalty
Summary
The facility failed to ensure that all employees had completed the required Iowa Criminal Background check and dependent adult/child abuse registry check before beginning work. This deficiency was identified for one out of five employees reviewed, specifically a Certified Nurses Assistant (CNA) referred to as Staff N. Staff N was hired on 2/4/24, but their personnel file lacked documentation of the Iowa Criminal Background Check. The facility's policy, as reviewed, indicated that background checks were not required for staff under a certain age, which contradicts federal regulations mandating background checks for all employees regardless of age. During interviews, the Human Resource Generalist confirmed that the facility policy did not require background checks for staff under a certain age. The Administrator, who was new to the facility, acknowledged awareness of the federal regulations requiring background checks for all employees but was unaware of the facility's policy that did not align with these regulations.
Failure to Provide Correct Diet Consistency for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents, specifically those on mechanically altered diets. During a lunch service observation, it was noted that four residents who required mechanical soft diets were served coleslaw instead of the steamed cabbage that was listed on the menu for their dietary needs. This error was attributed to Staff F, a Dietary Aide, who admitted to forgetting to serve the appropriate food to the residents on mechanical soft diets. The residents involved had varying levels of cognitive impairment and dietary requirements, including diagnoses of dysphagia. The facility's policy, titled 'Accuracy and Quality of Tray Line Services,' mandates that meals be checked against the therapeutic diet spreadsheet to ensure accuracy. However, this policy was not followed, as confirmed by Staff G, the Certified Dietary Manager, and Staff H, the Registered Dietitian, who both acknowledged that the menu and modified diets should have been adhered to.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage and sanitation practices, affecting 61 out of 63 residents. During a lunch service observation, a dietary aide, identified as Staff F, initially performed hand hygiene but subsequently failed to maintain it while serving food. Staff F used their left hand to handle hamburger buns directly, instead of using tongs, and continued to serve food without performing hand hygiene between tasks. This practice was repeated for all plates served during the observation period. The facility's hand washing policy, dated 2021, requires hand hygiene to be performed as often as necessary to prevent cross-contamination when changing tasks. Staff G, the Certified Dietary Manager, confirmed that Staff F should not have touched the buns with their hands and should have used tongs to open them.
Failure to Maintain Resident Dignity by Not Cleaning Food Debris
Penalty
Summary
The facility failed to uphold the dignity of a resident by not promptly addressing food debris left on the resident's clothing protector and face after a meal. The resident, identified as having severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 2, was dependent on staff for personal hygiene and required substantial assistance with eating. An observation noted that the resident had 2-3 tablespoons of orange food on their clothing protector and dry orange food on their chin, which was not cleaned up in a timely manner. The incident was confirmed by the resident's family member, who reported finding and cleaning the food debris from the resident's clothing protector and face several hours after lunch. The facility's policy on dignity, which emphasizes treating residents with respect and ensuring their well-being, was not adhered to in this instance. The Director of Nursing (DON) acknowledged that the clothing protector should have been changed and the resident's face cleaned before returning to their room.
Failure to Refer Resident for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer a resident for a Level II PreAdmission Screening and Resident Review (PASRR) evaluation after the resident was identified with newly evident or possible serious mental disorders. The resident, identified as Resident #48, had a negative Level I PASRR result but was later diagnosed with major depressive disorder and psychotic disorder with hallucinations. Despite these diagnoses, the facility did not follow up with a resubmission for a Level II PASRR evaluation, as required by their Behavioral Assessment, Intervention, and Monitoring policy. The resident's clinical records showed diagnoses of anxiety disorder, depression, and psychotic disorder, and the resident was on medications such as buspirone, donepezil, and sertraline. The facility's failure to act was confirmed during an interview with the Director of Nursing, who stated that the social worker should have resubmitted the PASRR for a Level II screening upon the new diagnoses. This oversight was identified during a review of the resident's chart, which lacked documentation of a follow-up PASRR submission.
Failure to Follow Care Plan for Resident Supervision
Penalty
Summary
The facility failed to adhere to a care plan for a resident with moderate cognitive impairment, depression, muscle weakness, and a history of a left fracture. The care plan, last revised on May 20, 2024, included an intervention initiated on April 2, 2024, requiring staff not to leave the resident unattended in a wheelchair while in his room due to a high risk of falls. However, during the survey, it was observed that the resident was left unattended multiple times while in a wheelchair, both in the hallway and in his room, despite the care plan's instructions. Interviews with staff members, including LPNs and CNAs, revealed a lack of awareness regarding the resident's supervision needs as outlined in the care plan. Staff members incorrectly believed the resident did not require supervision while in his room or in a wheelchair. The Director of Nursing also reported being unaware of the supervision requirement and acknowledged that the current care plan did not reflect the need for supervision. This oversight led to the resident being left unattended, contrary to the care plan's directives.
Failure to Accurately Measure and Administer Feeding Tube Formula
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the technical aspects of feeding tube management for a resident, identified as Resident #24. The resident, who had no cognitive impairment, was documented to have a feeding tube and required 330 mL of supplemental formula to be administered via PEG tube three times daily. However, observations revealed that the staff did not accurately measure the formula as per the physician's order. Instead, the staff member, identified as Staff E, was observed to 'eye' the formula, filling the bag just above the 300 mL line, rather than the prescribed 330 mL. This discrepancy was further evidenced when a significant amount of formula remained in the carton after administration, indicating that the correct volume was not being delivered. Additionally, the facility's procedures for medication administration through the feeding tube were not followed. Staff E was observed pushing medications with a piston syringe, rather than allowing them to flow by gravity as expected by the facility's standards. The Director of Nursing confirmed that the facility's expectation was for nurses to measure the supplemental formula using a graduated cylinder and to administer medications with gravity flow, highlighting a deviation from established protocols in the care of Resident #24.
Medication Storage Deficiency
Penalty
Summary
The facility failed to properly store medications in a locked storage area for one resident, as observed during a survey. On two separate occasions, a bottle of Tums was found sitting by the sink in the resident's room. The resident's clinical record did not include documentation of an assessment for self-administration of medications. An interview with the Director of Nursing revealed that the resident was not able to self-administer medications and no self-administration assessments had been completed. The facility's policy, revised in April 2007, requires that policies, procedures, and operational practices conform to current professional standards, which was not adhered to in this instance.
Incomplete Documentation of Oxygen Therapy in EHR
Penalty
Summary
The facility failed to maintain complete and accurately documented electronic health records for a resident, identified as Resident #5, who was observed wearing oxygen in his bedroom. Despite the resident's statement that he had been using oxygen almost daily for a couple of years and his care plan documenting oxygen therapy related to shortness of breath and a diagnosis of COPD, the most recent physician's order for oxygen had been discontinued in January 2023. A Licensed Practical Nurse (LPN) believed there was a PRN order for oxygen to maintain saturation above 90%, but upon review, no current order for oxygen was found in the resident's Medication Administration Records (MAR) or Treatment Administration Records (TAR) for May. The Director of Nursing (DON) confirmed that the facility's expectation was for the current oxygen order to be present in the resident's MAR, but it was missing. The DON suggested that the order might have been discontinued when the resident was hospitalized and not re-entered into the Electronic Health Records (EHR) upon their return. The facility's procedure for noting a physician's order required confirmation in the PointClickCare (PCC) system once processed by the pharmacy, but this step was evidently not completed for Resident #5's oxygen order.
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An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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