Laurens Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Laurens, Iowa.
- Location
- 304 East Veterans Road, Laurens, Iowa 50554
- CMS Provider Number
- 165219
- Inspections on file
- 19
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Laurens Care Center during CMS and state inspections, most recent first.
QAA Meeting Attendance Deficiency: The facility failed to ensure all required QAA members attended quarterly meetings. Review of QAPI attendance records showed the required team had not all attended a quarterly meeting since 5/27/25. The DON acknowledged that staff turnover, leadership changes, and the Infection Preventionist being pulled to work as a charge nurse affected attendance. The QAPI plan listed the required participants, including the Administrator, DON, MDS Coordinator, Infection Preventionist, Medical Director, Activity Director, Social Worker, and Dietary Manager.
Failure to Follow Medication Administration Standards: A CMA administered a nebulizer treatment and handed a resident an inhaler at the same time, allowing the resident to take two puffs immediately without being told to wait until the nebulizer treatment was complete or to wait between puffs. The CMA also did not offer a mouth rinse after the inhaler, despite the manufacturer’s instructions to rinse after use. The DON stated she had no prior knowledge of the action and confirmed the expectation to wait between medications and offer an oral rinse.
Failure to Provide Scheduled Restorative ROM Program: A resident with quadriplegia, depression, bipolar disorder, and CVA had a care plan for restorative ROM and stretching 5-7 times per week, but restorative therapy was missed on multiple occasions. The resident stated therapy was not provided when the restorative aide was off duty, while the restorative aide said floor staff were supposed to complete it. CNAs said they were not aware they were expected to provide the restorative program, and the DON stated staff should complete the same routine when the restorative aide was absent. The facility had no policy for restorative therapy.
Failure to document pneumococcal vaccine screening, education, and consent for 3 residents. Residents with intact cognition had prior pneumococcal immunizations on record, but the chart lacked documentation that they were educated about, offered, or consented to or refused PCV20 or PCV21. The IP stated the facility relied on physicians to track vaccine due dates and had no internal process for managing these immunizations.
A male resident with severe cognitive impairment and a history of inappropriate sexual behaviors was able to inappropriately touch the breasts of two female residents with cognitive impairments on multiple occasions. Despite interventions such as 15-minute checks and environmental modifications, staff were unable to consistently prevent these incidents, resulting in repeated episodes of resident-to-resident sexual abuse.
A resident with multiple diagnoses and no cognitive impairment was not assisted in obtaining medications through the VA pharmacy, despite being eligible and having documentation indicating veteran status. The facility did not complete the necessary steps to transition the resident's medications to the VA, resulting in the resident paying full price for medications. Staff interviews and record review confirmed the process was not completed due to miscommunication and staff turnover.
A facility failed to include a resident's antidepressant medication in their care plan, despite the resident having moderate cognitive impairment and receiving Mirtazapine for failure to thrive. The DON confirmed the omission, and the facility lacked a specific care plan policy, relying on federal regulations instead.
The facility failed to update care plans for two residents with changing needs. A resident with Alzheimer's required assistance with eating, contrary to their care plan stating independence. Another resident, documented as independent, needed limited assistance with eating, which was not reflected in their care plan. The facility did not revise care plans as required by regulations.
A facility failed to document oxygen therapy for a resident with moderate cognitive impairment and pneumonia. The resident was observed using oxygen at 2 liters per minute on several occasions, but the Treatment Administration Record only noted its use once without specifying the amount. The DON confirmed the absence of a policy for as-needed oxygen, relying instead on physician's orders, which should have been documented.
The facility failed to verify that a student CNA became certified and registered after completing the CNA course and taking the written exam. Discrepancies in test results led to the CNA working without proper credentials.
The facility failed to provide timely and correct Medicare Non-Coverage notices to two residents. One resident received the notice two days late, and both residents were given the incorrect SNF ABN form. Staff acknowledged the errors, and the facility lacked a specific policy for administering ABNs.
The facility failed to ensure bed hold notices were signed by the resident or the resident's responsible person when two residents were transferred out of the facility. Both residents' clinical records lacked the required bed hold forms, and the Director of Nursing confirmed the oversight.
The facility failed to use PPE and perform hand hygiene when exchanging water pitchers for residents suspected of having Norovirus. A CNA was observed entering multiple rooms without PPE, handling water pitchers, and not performing hand hygiene, despite the presence of contact isolation signs and PPE supplies. Interviews confirmed the need for contact isolation precautions due to suspected Norovirus.
The facility failed to provide the required 2-hour dependent adult abuse training within six months of hire for two CNAs. Staff D and Staff E completed the training beyond the mandated timeframe, which was confirmed by the Business Office Manager.
QAA Meeting Attendance Deficiency
Penalty
Summary
The facility failed to ensure all required members attended the quarterly Quality Assessment and Assurance (QAA) meetings. Review of QAPI meeting attendance sign-in sheets from March 2025 through April 2026 showed that all required team members had not attended a quarterly QAA meeting since 5/27/25. During an interview on 4/15/26 at 12:40 PM, the DON acknowledged that not all required team members had attended the QAA meeting quarterly and stated that staff turnover and leadership changes had affected attendance. She also said the Infection Preventionist had sometimes been required to work on the floor as a charge nurse and therefore had not always been able to attend the meetings. The facility’s QAPI Plan, updated 3/1/26, stated the facility would meet monthly to discuss ongoing or new issues in the nursing home, and identified the required participants as the Administrator, DON, MDS Coordinator, Infection Preventionist, Medical Director at minimum every 3 months, Activity Director, Social Worker, and Dietary Manager.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to provide professional standards of care when a CMA administered medications to a resident with diagnoses of hypertension, heart failure, anxiety, and depression, and a BIMS score of 15 indicating no cognitive impairment. During observation, the CMA administered Ipratropium-Albuterol inhalation solution via nebulizer and handed the resident a Budesonide-Formoterol inhalation aerosol inhaler at the same time. The resident removed the nebulizer mask and immediately inhaled two puffs from the inhaler before returning it to the CMA. The CMA did not instruct the resident to wait until the nebulizer treatment was complete, did not instruct the resident to wait one minute between puffs, and did not offer a mouth rinse after the inhaler was given. The manufacturer’s instructions for the inhaler state to rinse the mouth with water after use to prevent oral thrush, and the facility had no policy related to medication administration. The DON stated she had no prior knowledge of the action and confirmed the expectation was for staff to wait five minutes between administering medications and to offer an oral rinse after the inhaler.
Failure to Provide Scheduled Restorative ROM Program
Penalty
Summary
The facility failed to provide a restorative program for a resident with mobility concerns. Resident #6’s MDS documented diagnoses of quadriplegia, depression, bipolar disorder, and CVA, and the resident had a BIMS score of 15 indicating no cognitive impairment. The care plan, initiated on 9/12/2012, included a restorative rehab program with upper and lower extremity ROM exercises, shoulder pulleys, PROM, theraband exercises, and stretching to be completed 5-7 times per week. During interview, Resident #6 stated the facility was not providing restorative therapy five days a week and said she did not receive therapy when the restorative aide was off duty. Record review for the prior 30 days showed missed restorative therapy on March 20, March 25, March 27, March 30, and April 10. Staff A, the restorative aide, stated she works Monday through Friday except when she works every 3rd weekend as a CMA, and then she is off that Friday and Monday; she said floor aides were to complete restorative therapy using instructions in the EHR. Staff C and Staff D, CNAs, stated they were not aware they were supposed to provide restorative therapy for Resident #6 when the restorative aide was absent, and Staff D said she did not use the as-needed button in the EHR. The DON stated the restorative aide would tell staff when she would be gone so they knew to complete it, and that her expectation was for staff to complete the same routine as the restorative aide. The facility had no policy regarding restorative therapy.
Failure to Document Pneumococcal Vaccine Screening, Education, and Consent
Penalty
Summary
The facility failed to screen for eligibility, offer, provide education, and document consent or refusal for pneumococcal immunizations for 3 of 5 residents reviewed. Resident #6 had a BIMS score of 15 indicating intact cognition, and the record showed the last pneumococcal immunization was PCV13 on 10/5/2015. The clinical record did not document that the resident was educated about, offered, or consented to or refused PCV20 or PCV21. Resident #22 had a BIMS score of 13 indicating intact cognition, and the record showed the last pneumococcal immunization was PPSV23 on 10/15/2017. Resident #27 had a BIMS score of 15 indicating intact cognition, and the record showed the last pneumococcal immunization was PCV13 on 9/26/2017. For both residents, the clinical record did not document education, an offer of pneumococcal vaccination, or consent or refusal for PCV20 or PCV21. The Infection Preventionist stated the facility relied on physicians to track and notify staff when pneumococcal vaccines were due, and there was no internal process for managing these immunizations. The facility policy stated vaccines would be offered per physician order and current CDC or Iowa Department of Public Health recommendations.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically sexual abuse, by not preventing a male resident with a known history of inappropriate sexual behaviors from inappropriately touching two female residents on multiple occasions. The male resident, who had severe cognitive impairment and a history of making sexual comments and advances, was able to access and touch the breasts of two female residents, both of whom also had cognitive impairments. These incidents occurred despite the facility being aware of the male resident's behavioral history and having documented previous similar behaviors. The first female resident had severe cognitive impairment, aphasia, non-Alzheimer's dementia, and a traumatic brain injury. She required assistance with mobility and decision-making. On two separate occasions, the male resident was observed touching her chest, once under her shirt and once over her shirt, in common areas of the facility. In both cases, staff intervened after the inappropriate contact had already occurred. The second female resident, who had moderate cognitive impairment and a history of trauma, was also touched on the breast by the same male resident while being escorted to lunch. The male resident refused to stop when asked by staff and continued the inappropriate contact until physically separated. Despite the male resident's care plan including interventions such as 15-minute checks, increased monitoring, and environmental modifications (e.g., doorbells, closed doors), these measures were not effective in preventing repeated incidents of abuse. Staff interviews revealed inconsistent awareness and implementation of monitoring interventions, and there were lapses in supervision that allowed the male resident to access vulnerable residents. The facility's failure to ensure adequate supervision and effective implementation of interventions resulted in multiple instances of resident-to-resident sexual abuse.
Failure to Facilitate Resident Choice of Pharmacy for VA Medications
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was able to exercise the right to choose a pharmacy, specifically regarding the use of Veterans Administration (VA) pharmacy benefits. The resident, who had no cognitive impairment and diagnoses including diabetes, Alzheimer's disease, anxiety disorder, and agitation, was documented as a veteran eligible for VA medications. Despite this, the facility did not facilitate the process for the resident to receive medications through the VA, resulting in the resident paying full price for multiple medications. Documentation showed that the resident's spouse inquired about VA coverage, and the Social Services Coordinator, Administrator, and Director of Nursing were made aware of the issue. However, the process to obtain VA medications was not completed, and the resident continued to receive medications outside of the VA system. Staff interviews and record reviews revealed that the necessary steps to transition the resident's medications to the VA pharmacy were not followed through, partly due to staff turnover and miscommunication. The Administrator assumed the process was handled after initial paperwork was completed, but later discovered it had not been finalized. The record lacked evidence that the resident was ever successfully enrolled to receive VA medications, and staff confirmed that the resident was not receiving medications through the VA at the time of the review.
Failure to Include Antidepressant in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was receiving psychotropic medication. The resident, identified as having moderate cognitive impairment and an unspecified nutritional deficiency, was prescribed Mirtazapine, an antidepressant, to address failure to thrive. Despite the Care Area Assessment (CAA) indicating that the use of psychotropic medication should be addressed in the care plan to avoid complications and minimize risks, the resident's care plan did not include any mention of the antidepressant use. The Director of Nursing (DON) acknowledged that the Mirtazapine should have been included in the care plan and confirmed that it was missed. The facility did not have a specific policy on care plans but followed the Code of Federal Regulations on comprehensive person-centered care planning. This oversight was identified during a review of the resident's records and through staff interviews, highlighting a deficiency in the facility's care planning process.
Failure to Update Care Plans for Residents with Changing Needs
Penalty
Summary
The facility failed to ensure that the care plans for two residents were reviewed and revised after each assessment, as required by regulations. Resident #8, who had Alzheimer's disease and required substantial assistance with eating, was observed being fed by staff on multiple occasions, despite the care plan indicating that the resident ate and drank independently. The Director of Nursing (DON) confirmed that the resident's condition had declined and acknowledged that the care plan should have been updated to reflect the current status. The facility did not have a specific policy on care plans but followed federal regulations, which mandate that care plans be reviewed and revised by the interdisciplinary team after each assessment. Resident #14, diagnosed with non-Alzheimer's dementia, diabetes mellitus, and renal insufficiency, was documented as being independent with eating according to the Minimum Data Set (MDS) and care plan. However, staff documentation over a month-long period indicated that the resident required limited assistance with eating on 27 out of 30 days. This discrepancy between the care plan and the resident's actual needs was not addressed, indicating a failure to update the care plan to reflect the resident's current condition and care requirements.
Failure to Document Oxygen Therapy for Resident
Penalty
Summary
The facility failed to ensure proper documentation for a resident requiring oxygen therapy. Resident #11, who had moderate cognitive impairment and a diagnosis of pneumonia, was observed using oxygen at 2 liters per minute on multiple occasions. However, the Treatment Administration Record (TAR) for March 2025 only documented the use of oxygen on one day without specifying the liters used. The Director of Nursing confirmed that the facility lacked a policy for as-needed oxygen and relied on physician's orders, which should have been documented on the TAR if the resident received oxygen and at what setting.
Failure to Verify CNA Certification and Registration
Penalty
Summary
The facility failed to verify and ensure that a student CNA, Staff G, became certified and registered after completing the CNA course and taking the written exam. Staff G was hired as an environmental aide and later switched to a CNA role after reportedly passing the written exam on the third attempt. However, discrepancies were found between the test results provided by Staff G and those from the college, with the college indicating that Staff G failed all three attempts. Despite this, Staff G was allowed to work full-time as a CNA based on the incorrect test results she provided to the facility. The facility did not have a policy on nurse aide registry checks, which contributed to the oversight. The personnel file for Staff G lacked documentation of her registration on the Iowa Direct Care Worker Registry. The Business Office Manager and the DON were unaware of the discrepancy until they rechecked the registry and found that Staff G was not listed. The college confirmed that Staff G had failed the exam three times, and the document provided by Staff G appeared to have been altered. This failure to verify certification and registration led to Staff G working as a CNA without proper credentials, which was identified during the survey.
Failure to Provide Timely and Correct Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a notice of Medicare Non-coverage 48 hours in advance of services ending for one resident. Specifically, Resident #2, who had intact cognition and required significant assistance with mobility and transfers, was not given the Notice of Medicare Non-Coverage until two days after their skilled nursing facility (SNF) services ended. The social worker completed the notice paperwork late and apologized to the resident, who acknowledged and signed the forms on 10/04/23, despite the services ending on 10/02/23. Additionally, the facility used the incorrect Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) form for both Resident #2 and Resident #6, who also had intact cognition and required assistance with mobility and transfers. Resident #6 signed the incorrect ABN form on 8/29/23, even though their last covered day for SNF level of care was on 9/1/23. Staff interviews confirmed these deficiencies. The social worker acknowledged the errors and the late notice given to Resident #2. The facility administrator admitted that there was no specific policy for administering the Advance Beneficiary Notices (ABNs) and that the facility generally followed CMS regulations, aiming to issue written notifications within 48 hours of discharge from skilled services. The facility reported a census of 30 residents at the time of the survey.
Failure to Provide Bed Hold Notices
Penalty
Summary
The facility failed to ensure that bed hold notices were signed by the resident or the resident's responsible person when residents were transferred out of the facility. This deficiency was identified for two residents. Resident #35, who had diagnoses including spinal stenosis, heart failure, and renal insufficiency, was transferred to the hospital for intravenous antibiotics but lacked a bed hold form for the hospital stay. The facility's policy required providing bed hold information upon admission and at the time of temporary absence, but this was not followed in Resident #35's case. Similarly, Resident #4, who had moderately impaired cognition and multiple diagnoses including anemia, hypertension, renal disease, and a stroke, was admitted to the hospital for a urinary tract infection and intravenous therapy. The clinical record for Resident #4 also lacked documentation of a bed hold notice upon discharge to the hospital. The Director of Nursing confirmed that the facility did not complete the required bed hold forms for these residents, indicating a failure to adhere to the facility's policy on bed hold notifications.
Failure to Use PPE and Perform Hand Hygiene During Norovirus Outbreak
Penalty
Summary
The facility failed to use personal protective equipment (PPE) and perform hand hygiene when exchanging water pitchers for residents suspected of having the Norovirus in rooms 208, 209, and 213. Staff A, a Certified Nurses Aide (CNA), was observed entering these rooms without PPE, placing new water pitchers on bedside tables, picking up used water pitchers, and securing them against herself using her forearm. Staff A then placed the used water pitchers on a wheeled cart and proceeded to the next room without performing hand hygiene. This process was repeated for multiple rooms, despite the presence of contact isolation signs and PPE supplies outside the rooms, indicating the requirement for gowns, gloves, and designated equipment for contact isolation. Interviews with the Administrator, a Licensed Practical Nurse (LPN), the Infection Preventionist (IP), and the Director of Nursing (DON) confirmed that the residents in rooms 208, 209, and 213 required contact isolation precautions due to symptoms of suspected Norovirus, including nausea, vomiting, and diarrhea. The IP reported that test results for Norovirus were pending, and the DON confirmed that staff were expected to follow contact isolation precautions every time they entered the specified rooms. Despite these requirements, Staff A did not adhere to the necessary infection control protocols, leading to a deficiency in the facility's infection prevention and control program.
Failure to Provide Timely Dependent Adult Abuse Training
Penalty
Summary
The facility failed to provide the required 2-hour dependent adult abuse training within six months of hire for two employees, Staff D and Staff E. Staff D, a Certified Nursing Assistant (CNA), was hired on 3-23-23 and completed the training on 11-24-23, which is beyond the six-month requirement. Similarly, Staff E, also a CNA, was hired on 5-15-23 and completed the training on 11-24-23, also exceeding the six-month timeframe. The facility's policy mandates that each employee complete this training within six months of initial employment. This deficiency was verified and acknowledged by Staff F, the Business Office Manager, on 3-20-24.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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