Iowa City Rehab & Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Iowa City, Iowa.
- Location
- 3661 Rochester Avenue, Iowa City, Iowa 52245
- CMS Provider Number
- 165198
- Inspections on file
- 34
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Iowa City Rehab & Health Care during CMS and state inspections, most recent first.
A resident with paraplegia, dementia, malnutrition, and continuous PEG tube feeding at 75 mL/hr was repeatedly observed lying in bed with the head of the bed flat and without the ordered abdominal binder, despite physician orders for continuous tube feeding and binder use at all times. Staff allowed the feeding to run while the resident lay flat and while PEG tubing was under tension after a self-transfer from wheelchair to bed, and multiple staff entries into the room occurred without correcting the bed position or applying the binder. In interviews, staff acknowledged that the head of the bed should be elevated during continuous tube feeding and that the binder was needed to prevent the resident from pulling out the PEG tube, while the facility’s feeding tube policy lacked specific guidance on required head-of-bed positioning.
A resident with Alzheimer’s disease, diabetes, thyroid disease, and atrial fibrillation was admitted on time-limited hospital discharge medication orders that were written for 20 days. MAR review showed that numerous routine medications, including anticoagulants, cardiac, psychiatric, endocrine, and respiratory drugs, were administered only through the 28th of the month and then not scheduled or given for the next three days, and many were not scheduled at all the following month. An ED note documented that the resident’s daughter reported medications had been stopped without explanation and that the pharmacy indicated discharge meds had not been renewed. RNs and the NP gave conflicting accounts of who was responsible for renewing these orders, there was no documentation that nurses notified the provider about the 20-day limits, and the facility’s medication reconciliation and reordering policies requiring systematic review and timely reordering were not followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment, with observations of broken hygienic equipment, rusted heating/AC units, and significant dirt and grime buildup in multiple resident rooms. Staff confirmed ongoing issues with cleaning and equipment repair, and facility policy on routine cleaning and disinfection was not consistently followed.
Two residents did not receive prescribed medications as ordered due to staff failing to order and administer them in a timely manner. One resident missed multiple doses of a narcotic pain medication, while another experienced a delay in starting new medications for respiratory symptoms. These actions were not in accordance with facility policy requiring timely and accurate medication administration.
Three residents with conditions such as COPD, cerebral palsy, and morbid obesity were not provided with restorative nursing programs despite care plans indicating the need for exercise and therapy interventions. Residents expressed a desire to use exercise equipment to maintain or improve mobility, but were denied due to lack of staff and absence of a restorative program, as confirmed by staff and administration.
The facility did not provide enough nursing staff to meet resident needs, resulting in delayed responses to call lights and residents waiting extended periods for assistance. Staff and residents reported that low staffing, especially on one hall, led to frequent delays in care and unmet needs, contrary to facility policy requiring timely response.
Two residents experienced deficiencies in care when staff failed to follow physician orders for wound care, medication administration, and dietary management. Wound dressings were not changed as prescribed, medications were not administered according to schedule, and significant weight loss was not reported to the physician. Wound assessments lacked essential details, and documentation did not accurately reflect the care provided. Staff interviews confirmed inconsistencies in following orders and documentation practices.
A resident with intact cognition and multiple diagnoses was observed with a diuretic pill at bedside, which staff confirmed was taken only after checking back. The clinical record lacked documentation that the resident was assessed as safe to self-administer medications, contrary to facility policy requiring physician and care team determination before allowing self-administration.
A resident who was cognitively intact and discharged home from skilled nursing services under Medicare Part A did not receive the required Notice of Medicare Non-Coverage (NOMNC) due to a lack of staff training and absence of a facility policy, resulting in the resident not being informed of their appeal rights.
A resident with hemiplegia, stroke history, and dysphagia was repeatedly observed eating in bed with the head of the bed elevated less than 15 degrees, despite staff acknowledging the need for upright positioning to prevent choking. Staff practices were inconsistent, and the facility lacked a policy on safe meal positioning.
The facility did not implement a bladder training program or other interventions for a resident with reversible urinary incontinence, despite assessments indicating the resident could participate. Additionally, catheter tubing and drainage bags for another resident with a suprapubic catheter were repeatedly observed resting on or dragging along the floor, contrary to facility policy and infection control standards.
A resident with diabetes received insulin from an LPN who did not prime the insulin pen before injection, despite manufacturer instructions and facility expectations to do so. The LPN believed priming was only needed for the first use, leading to a significant medication error as the pen was not primed before administering the prescribed dose.
Staff were observed using nicotine vape pens in offices near the dining room and during activities with residents present, despite a facility policy restricting tobacco use to designated areas. Multiple staff confirmed these incidents, which occurred in violation of the facility's Tobacco Policy and in the presence of residents.
A resident with a seizure disorder and intact cognition repeatedly reported multiple daily seizures to staff, but nursing staff did not consistently assess, document, or notify the neurology provider as required by physician orders and facility policy. Staff interviews confirmed that although the resident's reports were communicated among staff, the necessary notifications and documentation were not completed.
The facility did not have an Infection Prevention Specialist or Infection Control Nurse, as required for effective infection control. The Administrator reported that the Assistant Director of Nurses, who previously handled infection control, left the facility a month ago, and a replacement was only found recently.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices, leading to a deficiency in infection control. Staff did not use gowns during high-contact activities, and rooms lacked appropriate signage and PPE. Interviews revealed a lack of staff education on EBP, exacerbated by the recent loss of key infection control personnel.
The facility failed to provide adequate staffing, resulting in delayed call light responses. On a morning, four call lights were observed blinking in the East Hall, with only one LPN present due to an aide's late arrival. This led to response times as long as 39 minutes. Interviews revealed that residents had previously complained about call light delays, and a call light audit confirmed the issue.
The facility failed to ensure proper personal hygiene in the kitchen when two male dietary employees with facial hair did not wear beard guards, as required by the facility's policy. The Dietary Manager acknowledged the oversight, noting that beard guards were available and had been used in the past.
The facility failed to ensure proper medication administration for two residents with moderate cognitive impairment. Medications were left unattended in residents' rooms without orders for self-administration, contrary to facility policy requiring staff to remain with residents until medications are taken.
A resident with severe cognitive impairment suffered burns from spilled coffee due to inadequate supervision and lack of assistive devices. Another resident, with impaired decision-making, was allowed to smoke independently, violating the facility's smoking policy. The facility failed to implement necessary interventions and ensure adherence to safety measures, resulting in unsafe conditions.
Two residents in a facility were observed with urinary drainage bags in contact with the floor, risking cross-contamination and UTIs. Despite care plans and staff expectations to keep bags off the floor, observations showed non-compliance. The facility lacked specific policies for handling urinary drainage bags, relying on a general infection control policy.
A resident on hospice care, requiring substantial assistance for eating, was observed being assisted by a CNA who used her personal cell phone during the meal, violating facility policy. The CNA attempted to hide her phone when noticed by a surveyor, claiming a family emergency. This action compromised the resident's dignity, as the facility's policies emphasize maintaining a dignified existence and restrict personal phone use to breaks.
Failure to Maintain Head-of-Bed Elevation and Abdominal Binder During Continuous PEG Feeding
Penalty
Summary
The deficiency involves the facility’s failure to maintain appropriate positioning and use of an abdominal binder for a resident receiving continuous PEG tube feedings. The resident was cognitively impaired, diagnosed with paraplegia, non-Alzheimer’s dementia, and malnutrition, and was dependent on continuous gastric tube feedings to meet nutritional needs. Physician orders specified NPO status, continuous Glucerna 1.2 at 75 mL/hr via PEG tube, and an abdominal binder to be worn at all times, placed on backwards to prevent removal by the resident. On multiple observations, the resident was found in bed with the head of the bed flat while the feeding pump continued to run at 75 mL/hr, and without the ordered abdominal binder in place. The PEG tubing was also observed under tension when the resident self-transferred from wheelchair to bed while the feeding remained attached to a pole fixed to the wheelchair. Throughout the observation period, nursing staff, including an RN and a CNA, passed by or entered the resident’s room several times without elevating the head of the bed or ensuring the abdominal binder was applied, despite acknowledging in interviews that the head of the bed should be elevated at least 30–45 degrees during continuous tube feeding and that the binder was required to prevent the resident from pulling out the PEG tube. The facility’s policy on care and treatment of feeding tubes stated that feeding tubes would be used in accordance with current clinical standards of practice with interventions to prevent complications, but it did not provide specific direction on head-of-bed positioning while a feeding pump was running. These actions and omissions led to the identified deficiency in providing appropriate care for a resident with a feeding tube.
Failure to Renew Time-Limited Discharge Medications Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident remained free from significant medication errors when routine medications were not reordered prior to the exhaustion of the supply, resulting in three full days without multiple prescribed medications. The resident had a moderate cognitive impairment with a BIMS score of 11/15 and diagnoses including Alzheimer’s disease, diabetes mellitus, thyroid disease, and atrial fibrillation. The resident had been admitted in early December with a series of hospital discharge medication orders written for 20 days. Review of the December Medication Administration Record (MAR) showed that numerous medications, including aspirin, atorvastatin, bupropion, vitamin D3, divalproex, donepezil, duloxetine, empagliflozin, levothyroxine, pantoprazole, polyethylene glycol, amiodarone, budesonide, Eliquis, formoterol, metoprolol, senna, and carbidopa-levodopa, were administered through December 28 but then had no further doses scheduled for December 29–31, as indicated by "x" marks for all scheduled times on those dates. Review of the January MAR revealed that many of these same medications were not scheduled at all, indicating that they had not been renewed after the initial 20‑day period. An ED note from early January documented that the resident’s daughter called EMS because the resident was missing appointments and medications had been stopped without explanation, and the daughter reported the resident appeared more confused and was not eating; the ED note further stated that, upon speaking with the pharmacy, it appeared the resident’s discharge medications from previous visits had not been renewed while she was going between rehab hospitals. Staff interviews confirmed that the medications were not administered on December 29, 30, and 31, and that there was no documentation that nurses had brought the 20‑day duration of the discharge medications to the provider’s attention. Nursing staff and leadership interviews revealed confusion and inconsistent understanding of responsibility for renewing time‑limited hospital discharge orders. One RN stated that when a resident has medications ordered for a certain time frame after admission, the nurse is responsible for notifying the physician to renew the orders, but also suggested that perhaps the pharmacy did not send the medications and reported believing it was the pharmacy’s responsibility to notify the doctor for renewal. Another RN verified that the resident’s medications were not administered for three days and described that an "X" on the MAR would indicate a scheduled medication, and that if a medication was not given there should be another code to indicate the reason; she also stated that if a medication was discontinued it would not appear on the MAR during pass and that the facility NP was responsible for reviewing medications after a hospital return. The NP could not recall the specific issue or explain why some medications had been discontinued. The DON stated she would have expected the nurse to question why medications were written to be discontinued after 20 days and to speak with the provider, and the ADON stated the nurse should always give discharge paperwork to the provider; the DON verified there was no documentation that nurses had alerted the provider about the 20‑day duration. Facility policies on Medication Reconciliation and Medication Reordering required systematic verification, transcription, ordering, and reordering of medications, including reordering when six or fewer doses remained, but these processes were not effectively carried out for this resident’s time‑limited discharge medications.
Failure to Maintain Safe and Clean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple environmental concerns observed during a survey. Staff interviews revealed that a hopper used for hygienic disposal of body waste had been out of order for an extended period, and the facility was in the process of obtaining bids for its repair. Additionally, staff acknowledged that the floors throughout the facility required cleaning and stripping. Direct observations identified several deficiencies in resident rooms, including moderate rust and missing paint on heating/air conditioning units, heavy buildup of dirt and dark substances on floors, and the presence of a moderate amount of black substance on baseboards. Multiple rooms were noted to have moderate to heavy buildup of dark-colored grime on the floors. Review of the facility's policy on routine cleaning and disinfection confirmed that these practices were not being consistently followed, as required to maintain a safe and sanitary environment.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medications as prescribed by physicians for two residents. For one resident with chronic pain, COPD, and diabetes, there was a lapse in the administration of scheduled Hydromorphone for pain management. The resident reported not receiving the medication for approximately 20 hours, receiving only an alternative medication that was not effective. Documentation showed multiple missed doses, and staff interviews confirmed that the medication was not ordered in time, compounded by delayed delivery due to bad weather. The medication administration record indicated missed doses, and progress notes reflected that staff had to contact hospice for a new supply after the medication ran out. For another resident with asthma, COPD, and other chronic lung disease, a provider ordered new medications, including an antibiotic, corticosteroid, and inhaler, due to ongoing respiratory symptoms. However, these medications were not started over the weekend as ordered, and administration only began several days later. Staff interviews confirmed that the delay was due to a failure to order the medications in a timely manner. Facility policy requires medications to be administered safely, timely, and as prescribed, but this was not followed in these cases.
Failure to Provide Restorative Program for Residents at Risk of Physical Decline
Penalty
Summary
The facility failed to provide a restorative program for three residents who were at risk of physical decline due to their medical diagnoses and risk of falls. Clinical record reviews and care plans for these residents indicated the need for interventions such as encouraging exercise, providing opportunities for physical activity, and therapy evaluations. Despite these documented needs, observations and interviews revealed that none of the residents were participating in a restorative program, and their requests to use exercise equipment or participate in exercises were denied due to lack of staff or program availability. One resident with chronic obstructive pulmonary disease, pain, diabetes, and spinal stenosis expressed a desire to use the exercise bike to help with leg pain and mobility but was told he could not use it without staff supervision, which was unavailable. Another resident with cerebral palsy and mobility issues reported that he previously used the exercise bike but was no longer able to do so because the facility lacked staff to oversee the activity. He felt he was getting weaker as a result. A third resident with morbid obesity and respiratory failure also wanted to use the therapy room equipment but was similarly denied due to staffing shortages. Staff interviews confirmed that there was no restorative program in place at the facility, and the occupational therapist stated that although she had identified residents who would benefit from such a program, it had not been implemented. The facility's own policy required restorative nursing care to promote safety and independence, but this was not being followed. The administrator acknowledged the absence of a restorative program and indicated that other issues had taken priority.
Insufficient Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by prolonged call light response times and staff and resident reports of inadequate staffing. Observations showed that call lights in resident rooms remained unanswered for extended periods, such as one instance where a call light was activated at 10:40 AM and not answered until 10:58 AM, and another where a resident's call light was activated at 12:15 PM and not addressed until 12:38 PM. During these periods, residents were observed waiting for assistance, including one resident who was unable to begin eating lunch until staff responded to her call light and assisted her with positioning in bed. Interviews with staff and residents confirmed that staffing levels were insufficient, particularly on the East Hall, where only one aide was scheduled instead of the usual two. Residents reported that call lights often went unanswered for up to an hour on all shifts when staffing was low, and staff corroborated that they sometimes had to work late to complete resident care tasks such as baths. The facility's own policy requires timely response to call lights and holds all staff responsible for responding, but these procedures were not consistently followed due to inadequate staffing.
Failure to Follow Physician Orders and Inadequate Wound Care Documentation
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for two residents, resulting in multiple deficiencies. For one resident with complex medical conditions including peripheral vascular disease, renal failure, and recent abdominal surgery, staff did not implement or document physician-ordered treatments as prescribed. Orders for wound care, medication administration, and dietary management were not consistently followed. For example, wound dressings were not changed as frequently as ordered, and medications such as potassium chloride and ferrous sulfate were not administered according to the prescribed schedule. Additionally, significant weight loss was not communicated to the physician, and there was no documentation of the resident's refusal to participate in therapy or the absence of bowel movements. Wound assessments for the same resident were incomplete, lacking essential details such as wound measurements, tissue condition, drainage, and signs of infection. The clinical record did not contain accurate or sufficient documentation of wound status or physician notification regarding the resident's deteriorating condition. During a physician visit, it was noted that all dressings were dated several days prior and had not been changed as ordered, and the resident reported not having a bowel movement for several days. The resident was subsequently hospitalized for failure to thrive, poor wound healing, and weight loss. For another resident with a history of cancer and surgical wound infection, staff failed to follow wound care orders by not using the prescribed wound cleanser and documenting wound care as completed when it had not been performed. Observations revealed wound drainage on the resident's clothing and that wound care supplies were available but not used as ordered. Staff interviews confirmed that wound care was not always provided according to physician instructions, and documentation practices did not accurately reflect the care delivered.
Failure to Assess and Care Plan for Resident Self-Administration of Medication
Penalty
Summary
A deficiency occurred when the facility failed to assess and care plan for a resident to self-administer medications. The resident, who had diagnoses including heart failure, diabetes, and shortness of breath, was noted to have intact cognition with a BIMS score of 14 out of 15. The care plan addressed diuretic therapy for hypertension, and the medication administration record showed an order for bumetanide 1 mg twice daily. During observation, the resident was found with a pill in a medication cup at the bedside and stated it was a pill to make him urinate, indicating he had access to the medication before staff ensured it was taken. Staff interview confirmed that the LPN checked on the resident and verified the pill was taken after the fact. However, the clinical record did not contain documentation that the resident was assessed as safe to self-administer medications. Facility policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary care planning team determine the resident has the decision-making capacity to do so safely. This process was not documented for the resident involved.
Failure to Provide Notice of Medicare Non-Coverage at Discharge
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from skilled nursing services under Medicare Part A. Clinical record review showed that the resident had a planned discharge to home and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident was capable of independently understanding written instructions. However, there was no documentation of the required NOMNC being given to the resident at the time of discharge. Interviews revealed that the responsibility for completing beneficiary notification forms, including the NOMNC, had recently shifted from the business office to the social worker. The social worker, who had started a few weeks prior, did not complete the NOMNC for the resident due to a lack of training. The administrator confirmed the absence of a facility policy addressing beneficiary notification of non-coverage and acknowledged that the resident did not receive information on appeal rights as a result.
Failure to Ensure Safe Positioning During Meals
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia, cerebral infarction, and dysphagia was repeatedly observed eating meals while lying in bed with the head of the bed elevated less than 15 degrees. The resident's care plan noted risks related to altered nutritional status and swallowing difficulties. Despite this, multiple observations showed the resident eating in a reclined position, and the resident reported some difficulty eating in that position. Staff interviews revealed inconsistent practices, with some staff stating they positioned the resident upright for meals, while others acknowledged the resident sometimes refused to be repositioned. The Director of Nursing confirmed that residents should be upright during meals, but stated the resident was resistant to having the bed elevated. The facility did not have a policy on positioning residents while eating. The lack of consistent implementation of safe positioning practices and absence of a formal policy contributed to the failure to ensure the resident was positioned safely during meals, as required to prevent accidents such as choking.
Failure to Implement Bladder Training and Maintain Catheter Care Standards
Penalty
Summary
The facility failed to develop and implement interventions to attempt to restore or improve bladder function for a resident with urinary incontinence. The resident, who had diagnoses including heart failure and diabetes and was assessed as always incontinent of urine and frequently incontinent of bowel, was found to have intact cognition and the ability to communicate the urge to void. Despite an assessment indicating the incontinence was likely reversible and that the resident could participate in a toileting program, there was no evidence in the clinical record of a bladder training program or other interventions being carried out to address the incontinence. The resident also reported not recalling any bladder training or interventions to assist with regaining continence. Additionally, the facility failed to ensure proper catheter care for another resident with a suprapubic catheter. Observations showed that the resident's catheter tubing and drainage bag were repeatedly found resting on or dragging along the floor, both in the resident's room and in the hallway. Staff were observed rehanging the tubing and bag, but the issue persisted, with the tubing continuing to come into contact with the floor and being stepped on by the resident. Multiple staff members acknowledged having seen the tubing on the floor and identified concerns about cleanliness and the potential for the catheter to be pulled. Facility policy required that catheter tubing and drainage bags be kept off the floor and that appropriate services and treatment be provided to help restore or improve bladder function. Despite these policies, the facility did not implement a toileting plan or bladder training for the resident with incontinence, nor did it consistently ensure that catheter tubing and drainage bags were kept off the floor for the resident with a suprapubic catheter.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to prime an insulin pen prior to administering insulin to a resident diagnosed with diabetes, depression, and lack of coordination. The resident was observed receiving insulin injections daily, and during the observed medication administration, the LPN stated that priming was only necessary for the first use of the pen. The LPN proceeded to inject the resident with four units of insulin without priming the pen, contrary to the manufacturer's instructions, which require priming before each injection. Review of the resident's medication orders confirmed the use of a Humalog KwikPen with a sliding scale for insulin administration. The facility's policy on administering medications emphasized safe and timely administration as prescribed, but there was no specific policy regarding insulin pen use. The Director of Nursing confirmed that staff should prime insulin pens prior to each injection, and the manufacturer's instructions also directed priming before every use.
Staff Vaping in Common Areas Violates Resident Rights and Facility Policy
Penalty
Summary
Staff members were observed using nicotine vape pens in common areas of the facility, specifically in offices located off the dining room and during activities such as bingo, while residents were present. Multiple staff, including a CNA, CMA, and housekeeping, reported witnessing activities staff and office staff vaping inside their offices, with doors open and in close proximity to residents. These actions occurred despite the facility having a designated outdoor smoking area and a policy prohibiting the use of tobacco products, including vapes, in patient care areas and non-designated locations. The facility's Tobacco Policy, dated 9/21/23, clearly directed that employees are only permitted to use tobacco products in designated areas and are not allowed to carry such items in patient care areas. Despite this, staff interviews confirmed repeated violations of this policy, with vaping occurring in offices adjacent to resident common areas and during resident activities. The DON acknowledged observing this behavior and stated she directed the staff member to stop, while the Administrator claimed to be unaware of such incidents.
Failure to Assess and Notify Physician After Resident-Reported Seizure Activity
Penalty
Summary
The facility failed to assess a resident and notify the physician after the resident self-reported seizure activity. The resident, who had a documented history of seizure disorder, multiple sclerosis, cerebrovascular accident, schizophrenia, and depression, was cognitively intact and reported experiencing multiple seizures per day. The care plan included specific interventions for post-seizure treatment, documentation, and seizure precautions, and there was a physician order to notify neurology if an increase in seizures was noted. Despite these directives, clinical record review showed only one documented note of a self-reported seizure during the review period, with no further documentation of seizure activity. Multiple staff interviews revealed that the resident frequently reported seizures to staff, who would either check on her or report to the charge nurse. However, nursing staff, including an RN and LPN, admitted to not notifying the neurology provider regarding the resident's reported increase in seizures, as required by the physician's order and facility policy. The facility's policy required prompt notification of the physician for changes in a resident's condition, including specific instructions to notify for changes such as increased seizure activity. Staff interviews indicated a lack of consistent assessment and documentation of the resident's reported seizures, and the required notifications to the physician or neurology provider were not made, despite repeated self-reports by the resident.
Failure to Employ Infection Prevention Specialist
Penalty
Summary
The facility failed to employ an Infection Prevention Specialist, which is a requirement for maintaining an effective infection prevention and control program. During a review of the facility's staff list, it was observed that there was no designated Infection Prevention Specialist or Infection Control Nurse. The Administrator, identified as Staff F, reported that the facility had lost both the Director of Nurses and the Assistant Director of Nurses approximately one month prior. The Assistant Director of Nurses had been responsible for infection control, and since their departure, the facility had not been able to find a suitable replacement for this critical role until the day before the surveyor's interview.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to standard and transmission-based precautions, specifically Enhanced Barrier Precautions (EBP), for four residents, leading to a deficiency in infection prevention and control. Resident #2, who had a surgical wound and an indwelling Foley catheter, did not have appropriate signage or personal protective equipment (PPE) available outside their room. Staff members entered the room and provided care without donning gowns, contrary to the care plan directives. Resident #3, who had open areas on the coccyx and underneath the right breast, also lacked EBP signage and PPE in their room. Staff provided incontinence care and wound dressing changes without wearing gowns, despite the care plan indicating the need for EBP. Similarly, Resident #5, with a suprapubic catheter, had no EBP signage, and staff failed to wear gowns during high-contact activities, such as incontinence care and catheter maintenance. Resident #4, who had a suprapubic indwelling urinary catheter, also did not have EBP signage or PPE readily available. Staff entered the room and performed care activities without donning gowns, as required by the facility's policy. Interviews with staff revealed a lack of awareness and education regarding EBP, compounded by the recent loss of the Director of Nurses and Assistant Director of Nurses, who were responsible for infection control oversight.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed response times to call lights. On the morning of January 13, 2025, four call lights were observed blinking in the East Hall, indicating that residents in rooms 31, 37, 38, and 45 were requesting assistance. At that time, only one LPN, Staff A, was present on the wing, as the scheduled aide had not yet arrived due to car troubles. This staffing shortage led to prolonged response times, with the longest being 39 minutes for one of the rooms. Interviews with residents and staff revealed that the issue of delayed call light responses was not isolated. Resident #6 mentioned that call lights are sometimes not answered promptly when there is insufficient staff to assist with her transfers, which require two staff members. The Director of Nursing, Staff C, admitted to not regularly conducting call light audits unless a problem is reported, and no recent complaints had been noted. However, a call light audit conducted on January 14, 2025, confirmed the delays, and the Activities Director, Staff D, reported that residents had previously voiced complaints about call light response times during a resident council meeting in October 2024.
Failure to Ensure Proper Personal Hygiene in Kitchen
Penalty
Summary
The facility failed to ensure proper personal hygiene practices in the kitchen area, leading to a deficiency in food safety standards. During an observation, two male dietary employees were seen working in the kitchen with hair nets but without beard guards, despite having facial hair. This was contrary to the facility's policy, which mandates that all male employees with facial hair must wear beard guards. The Dietary Manager acknowledged the expectation for facial hair to be covered and admitted he had not noticed the staff's non-compliance at the time of the observation.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for two residents with moderate cognitive impairment. Resident #31, diagnosed with cerebral infarction, cognitive communication deficit, and dysphagia, was observed with a medication cup containing two white tablets on the bedside table. The resident indicated the medication was Tylenol and intended to take it later, despite the medication administration record showing the dose was signed as given by a Licensed Practical Nurse. There was no physician order for self-medication administration for this resident. Similarly, Resident #32, with diagnoses including obstructive hypertrophic cardiomyopathy, psychoactive substance dependence, and other conditions, was found with a medication cup containing several pills, including Gabapentin, unattended on the bedside table. The Certified Medication Aide could not identify the other medications and reported the medications were discarded. The facility's policy required medication staff to remain with residents until all medications were taken, which was not followed in these instances.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to protect a resident from environmental hazards, resulting in a resident acquiring first-degree burns from spilled coffee. Resident #4, who has severe cognitive impairment and physical behavioral symptoms, was not provided with adequate supervision or appropriate assistive devices, such as a lidded mug, to prevent the incident. Despite the resident's known morning tremors and jerky movements, staff did not implement necessary precautions, leading to the resident spilling hot coffee on herself. The care plan and dietary slip lacked updates or interventions to address the risk of hot liquid spills. Additionally, the facility did not ensure that another resident, Resident #28, was properly assessed for independent smoking. Despite having impaired decision-making and a history of smoking in undesignated areas, the resident was allowed to smoke independently without proper supervision. The resident frequently smoked outside the designated area, discarded cigarette butts improperly, and did not adhere to the facility's smoking policy. Staff inconsistently enforced the smoking policy, and the resident's care plan did not adequately address the risks associated with his smoking behavior. The facility's failure to identify and mitigate risks associated with hot liquids and smoking behaviors resulted in unsafe conditions for the residents. The lack of timely interventions and adherence to policies contributed to the incidents involving Resident #4 and Resident #28, highlighting deficiencies in the facility's supervision and environmental safety measures.
Inadequate Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate catheter care to prevent potential cross-contamination that could lead to urinary tract infections (UTIs) for two residents. Resident #17, who has severe cognitive impairment and a neurogenic bladder, was observed multiple times with the urinary drainage bag and tubing in direct contact with the floor. The care plan and Kardex for Resident #17 directed staff to wear protective gear during high-contact care and to position the catheter bag below the bladder level, but they lacked specific instructions to keep the bag and tubing off the floor. Observations revealed that the urinary drainage bag was often on the floor, and a family representative expressed concerns that this had contributed to past UTIs and hospitalizations. Resident #41, who has intact cognition and requires total staff assistance, was also observed with the catheter bag lying on the floor. The care plan for Resident #41 included goals to prevent catheter-related trauma and complications, but the observation indicated a failure to maintain proper catheter care. Interviews with staff, including a CNA and RN, confirmed that the expectation was to keep the urinary drainage bags off the floor by securing them to the bed frame. However, the facility lacked a specific policy for handling urinary drainage bags, relying only on a general infection control policy. The facility's infection control policy, last reviewed in 2020, aimed to prevent the transmission of infections and manage nosocomial infections. Despite this, the lack of specific guidelines for urinary drainage bag handling contributed to the observed deficiencies. The Administrator acknowledged the absence of a policy for urinary drainage bags and suggested using a wash basin to keep them off the floor, indicating a gap in the facility's infection prevention and control program.
Violation of Resident Dignity Due to Unauthorized Phone Use
Penalty
Summary
The facility failed to uphold the resident's rights and dignity for a resident on hospice care. The resident, who had severe cognitive loss and required substantial assistance for eating, was observed being assisted by a CNA who was using her personal cell phone during the meal. This action was against the facility's policy, which allows personal phone use only during breaks. The CNA attempted to conceal her phone when noticed by the surveyor and claimed it was due to a family emergency, although she did not show any emotional distress. The resident's care plan indicated a need for specific communication techniques and a homelike environment to maintain comfort, which were not adhered to during this incident. The facility's policies, including the Resident Rights and Responsibilities Policy and the Wireless Mobile Device Policy, emphasize the importance of maintaining a dignified existence for residents and restricting personal phone use to non-working times. Despite these policies, the CNA's actions during the meal compromised the resident's dignity and the facility's standards.
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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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