Lenox Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lenox, Iowa.
- Location
- 111 East Van Buren, Lenox, Iowa 50851
- CMS Provider Number
- 165235
- Inspections on file
- 21
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Lenox Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple failures in infection prevention and control, including improper use of Enhanced Barrier Precautions (EBPs) for two residents and deficient wound care technique for another. One resident with an indwelling catheter had an EBP care plan requiring gown and glove use during high-contact care, yet CNAs performed transfers, toileting, and catheter handling wearing only gloves. Another resident with diabetic foot ulcers received wound care from an RN who brought a dressing cart into the EBP room, repeatedly opened drawers and handled supplies with contaminated gloves, placed soiled items on the cart, and then reused the cart elsewhere, contrary to facility wound care and infection control policies. Additionally, the facility lacked a fully developed water management program: the Maintenance Director did not know the water flow diagram or Legionella prevention responsibilities, blueprints did not identify service areas or stagnant water risks, flushing of sinks and toilets was not on housekeeping checklists, and devices such as a whirlpool and a fish aquarium lacked documented maintenance protocols, despite policy requirements for annual assessment and control of Legionella and other waterborne pathogens.
Kitchen sanitation, food labeling, and hair restraint failures were observed in the dietary area. Surveyors found unlabeled and undated food items, open containers and spilled contents in refrigerators, heavy ice buildup in a freezer, and a dusty vent/screen above the prep area. During meal service, one cook had uncovered beard and mustache hair, and another cook prepared food without a hair net. The DM stated food items should be dated when received and opened, and that facial hair should be covered while preparing or serving food.
A resident with continuous O2 via NC was observed on a patio while several residents were smoking nearby, including one resident standing about 2 to 3 feet from the portable O2 tank with a lit cigarette. Staff were unsure of the required separation distance, and the smoking policy prohibited O2 use in the smoking area but left the distance requirement blank.
Failure to document non-pharmacologic interventions for residents receiving psychotropic medications. Three residents with diagnoses including dementia, anxiety, depression, psychotic disorder, and PTSD had care plans and behavior monitoring records that did not identify or consistently document nonpharmacological approaches before PRN or other psychotropic use. Staff interviews showed inconsistent understanding of the interventions being used, while the DON stated staff should have implemented and documented them.
A resident with MS, seizure disorder, and respiratory failure was receiving a scheduled anticonvulsant ordered BID. During a medication observation, a CMA prepared to administer the drug even though the medication card had two labels and one showed an expiration date of 10/2024. The ADON and DON stated the expiration date should have been checked before administration, and the facility policy required staff to identify expired medication.
Two residents experienced extended periods without a bowel movement, and staff failed to consistently follow physician orders for PRN laxatives and bowel protocols. Medication administration and care plan interventions were not reliably documented or implemented, and there was a lack of required assessments when interventions were ineffective or refused. Staff interviews revealed confusion over bowel movement tracking and the absence of clear facility policies for bowel management and medication administration.
Staff did not adhere to infection prevention protocols while providing catheter care to a resident on Enhanced Barrier Precautions. Hand hygiene and glove changes were missed between tasks, contaminated PPE was worn outside the resident's room, and catheter equipment was not properly cleansed, contrary to facility policy and expectations.
A resident with no cognitive impairment was unable to access personal funds managed by the facility during weekends or evenings, contrary to the facility's policy. The Business Office Manager and Administrator were the only staff with access to the funds, and they were not available outside regular working hours. This resulted in the resident being unable to purchase items when desired.
The facility did not follow the prescribed menu and portion control guidelines for residents on a mechanical soft diet. Staff H processed 8 meatballs but served only 1/3 cup to the last resident, contrary to the requirement of 2 ground meatballs per serving. Both the Certified Dietary Manager and the Contract Registered Dietitian confirmed that all processed meatballs should have been served, highlighting a deficiency in meeting the nutritional needs of 4 residents.
The facility failed to maintain an appetizing and safe temperature for mechanical soft meatballs during lunch service. The AM Cook recorded a temperature of 95 degrees, which was below the required 135 degrees. Both the Certified Dietary Manager and the Contract Registered Dietitian confirmed the deficiency, noting that the facility's policy mandates hot food temperatures of no less than 140 degrees when served.
The facility failed to store food according to professional standards, with several items in the refrigerator dated beyond the facility's policy of discarding after three days. Additionally, a thermometer was not sanitized before rechecking the temperature of reheated meatballs. Staff acknowledged these lapses, which were against the facility's policy.
A CNA witnessed another CNA inappropriately touching a resident but failed to report the incident within the required two-hour timeframe. The incident was observed at 12:30 PM, but the Assistant Director of Nursing was not notified until after 3:10 PM, violating the facility's policy on immediate reporting of abuse allegations.
Two residents in an LTC facility were found to have incomplete care plans, leading to deficiencies in their care. One resident with severe cognitive impairment and multiple diagnoses lacked a care plan for oxygen use, while another resident with complex medical conditions had no care plan for therapy or repositioning. Staff interviews revealed inconsistencies in care, and the facility's policies on individualized care plans were not followed.
The facility failed to update care plans for three residents, including a resident whose walk to dine program was discontinued, another who required smoking interventions, and a third whose POA was not invited to a care conference. Staff acknowledged the care plans were not up to date, and the DON emphasized the need for accurate documentation and family involvement.
A facility failed to provide necessary restorative care to a resident with multiple contractures and other medical conditions. The resident's care plan lacked interventions for restorative therapy, and recommended orthotic devices were not ordered. A system error led to the removal of the restorative program from the EHR, as acknowledged by the DON and Administrator. The resident was discharged from occupational therapy without progress, despite the facility's policy emphasizing individualized care.
A resident experienced significant weight loss due to the facility's failure to maintain nutritional status. The resident, with multiple health conditions, was not consistently awakened for meals, and staff were unaware of the weight loss. The Registered Dietitian was not informed of the issue, and meal refusals were not documented, leading to inadequate monitoring and care.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. A resident received incorrect dosages of Omeprazole and vitamin C due to errors in the EHR and lack of verification against the MAR. The resident had memory issues and multiple diagnoses, including Alzheimer's and dementia.
A facility failed to follow proper infection control practices during the care of a resident with complex medical needs. An LPN did not perform hand hygiene after glove removal during tracheostomy care, and two CNAs missed hand hygiene opportunities during personal care. The DON acknowledged these lapses, which were against the facility's policy.
A resident with multiple medical conditions, including cerebral palsy and quadriplegia, did not receive adequate assistance with activities of daily living (ADLs) in a facility. The resident was not repositioned regularly, despite needing it to prevent skin breakdown, and received fewer baths than required. Staff believed an air flow mattress provided sufficient pressure relief, but the facility's policies on repositioning and ADLs were not followed.
Inadequate Infection Control Practices and Water Management Program
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program, including improper use of Enhanced Barrier Precautions (EBPs), incorrect wound care practices, and an incomplete water management program. For one resident with heart failure, diabetes, COPD, intact cognition, and an indwelling urinary catheter, the MDS and care plan documented the need for EBPs due to the catheter and directed staff to use gowns and gloves during high-contact care such as transfers, toileting, and catheter care, with hand hygiene before and after care. Surveyors observed that although an EBP sign was posted on the resident’s door and staff wore gloves, two CNAs transferred the resident with a mechanical lift, handled the catheter, removed the resident’s pants and brief, placed a bedpan, and later performed pericare and catheter site cleansing without wearing gowns during these high-contact activities, contrary to the facility’s EBP policy. For another resident with diabetes, peripheral venous insufficiency, lymphedema, and diabetic ulcers on the toes of the left foot, the care plan and TAR directed daily wound care using Vashe solution, betadine, and gauze dressings. During an observed wound treatment, an RN donned mask, gown, and gloves and brought a dressing supply cart into the resident’s room, despite the resident being on EBPs. The RN opened saline bottles and cart drawers, obtained gauze, and performed skin fold and groin cleansing, then removed soiled dressings from the resident’s left foot, cleansed and treated the wounds, and applied new dressings. Throughout the procedure, the RN repeatedly opened and closed cart drawers and handled supplies on the cart with contaminated gloves, placed tape on top of the cart, moved an isolation gown in the drawer, retrieved a pen from a uniform pocket, and wrote on tape while using the cart surface, then returned supplies to the drawers. The RN also placed a soiled pad and towel on top of the cart, later removed the gown and put it in the trash on the side of the cart, and then pushed the same cart to another room and handled the soiled pad and towel again. These actions conflicted with the facility’s wound care policy requiring use of a disposable barrier for supplies and prohibiting return of disposable supplies to the cart, as well as the infection control and hand hygiene policies requiring proper handling of equipment, soiled linens, and glove use with hand hygiene when moving from dirty to clean areas. The facility also lacked a comprehensive and effectively implemented water management program to control Legionella and other waterborne pathogens. The Maintenance Director reported not knowing the location of the water flow diagram, who was responsible for Legionella preventive procedures, or which parts of the building were supplied by the two water heaters. Review of facility blueprints did not identify the service areas for each water supply line or the locations of high-risk stagnant water areas. The Housekeeping supervisor stated that staff flushed sinks and toilets during deep cleaning but that this task was not included on the deep clean checklist, and the checklist itself did not list toilet or sink flushing. The Administrator reported that a whirlpool near the DON’s office was temporarily nonfunctioning and believed it was the last water-supplied device in that hall’s water supply sequence. An annual Legionella environmental assessment documented the presence of a whirlpool without filter change or backwash documentation and a fish aquarium maintained at 77°F without a maintenance protocol, with the last cleaning date noted. These findings did not align with the facility’s water management policy, which required annual assessment of the water system to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, and to specify interventions and monitoring when risks were identified. The infection prevention and control policy stated that all staff were responsible for following infection control policies and procedures, that equipment must be cleaned and disinfected per facility policy, and that soiled linen should be collected at the bedside, placed into a linen bag, and then taken to a soiled utility room. The handwashing/hand hygiene policy emphasized that glove use does not replace hand hygiene and that integrating glove use with routine hand hygiene is best practice for preventing infection spread. During interviews, the ADON confirmed that EBPs are used to prevent the spread of germs and protect residents and staff, acknowledged that the dressing supply cart should not have been taken into a room for a resident on EBPs, and agreed that the RN had touched drawers and items on the cart with contaminated gloves, contrary to expectations that staff change gloves and sanitize hands when soiled or when moving from dirty to clean areas. The Administrator later acknowledged that the facility could have done better at implementing the water management plan.
Kitchen sanitation, food labeling, and hair restraint failures
Penalty
Summary
The facility failed to maintain clean and sanitary kitchen conditions and failed to properly label and store food items during kitchen observations. On the initial kitchen tour, surveyors found an open carton of liquid whole eggs in the Kenmore refrigerator without an open date, a plastic bag of what appeared to be uncooked hamburger patties with no label or date, a container of whipped salad dressing with splatters on the outside and lid, an open package of shredded lettuce spilled onto the shelf, a carton of apple juice with the top corner torn off and no open date, heavy ice buildup in the Frigidaire freezer, and a dusty vent/screen above the food prep counter. On the follow-up kitchen tour, the unlabeled and undated hamburger patties remained in the refrigerator, the salad dressing and shredded lettuce were still improperly stored, the freezer still had heavy ice buildup, and the vent/screen remained dusty and dirty. The facility also failed to ensure dietary staff fully covered hair during food preparation and service. During lunch service, a cook wore a hair restraint but had a moderate portion of beard/facial hair under the chin uncovered and no restraint over the mustache, while preparing and serving food to residents in the dining room. On another observation, a cook was seen cooking omelettes on a griddle without a hair net and stated she had forgotten it in her car. The Dietary Manager reported that food and beverage items were expected to be labeled with the received date and dated when opened, and that facial hair such as a beard and/or mustache needed to be covered while staff were in the kitchen and whenever food was prepared or served. The kitchen cleaning checklist did not include tasks for defrosting freezers, cleaning/dusting light fixtures, or cleaning the vent/screen above the food prep counter.
Oxygen Used Near Smoking Residents
Penalty
Summary
The facility failed to ensure that oxygen was kept away from residents who were smoking for 1 of 1 resident observed with oxygen in use. Resident #13 had diagnoses including CVA, anemia, hypertension, and CHF, and the MDS indicated the resident did not use tobacco but did use continuous oxygen. The care plan documented continuous O2 via nasal cannula due to risk for altered oxygen levels, chest pain, and shortness of breath, and the order summary showed continuous oxygen at 1.5 to 2 liters per minute. During observation, Resident #13 was seated in a wheelchair on the patio with portable oxygen connected and running at 2 liters per minute while several residents were smoking nearby. A male resident was observed approximately 2 to 3 feet from the resident's portable oxygen tank while holding a lighted cigarette. Resident #13 stated she did not know the smokers would be coming out to smoke. Staff interviews showed that smoking residents were taken to a designated smoking patio, nonsmoking residents used the front patio, and staff did not know how far a smoking resident should be kept from someone on oxygen. The Administrator stated she preferred a resident on oxygen to be a little ways away from someone smoking, estimating probably 20 feet, while the facility's smoking policy stated oxygen use in the smoking area is prohibited and left the distance requirement blank.
Failure to Document Non-Pharmacologic Interventions for Residents Receiving Psychotropic Medications
Penalty
Summary
The facility failed to identify and consistently document non-pharmacologic behavior interventions for 3 residents who received psychotropic medications. Resident #3 had diagnoses including non-Alzheimer's dementia, anxiety, depression, psychotic disorder, and schizophrenia, with an MDS showing a BIMS score of 15/15 and dependence for most ADLs and mobility. The care plan directed staff to attempt nonpharmacological interventions before PRN medications, but it did not specify what interventions to use. The EHR behavior monitoring history from 2/21/26 through 3/22/26 did not include non-pharmacological interventions, and progress notes also lacked documentation of such interventions for multiple behaviors. Staff interviews reflected inconsistent understanding of what interventions were being used, including letting the resident sleep and approaching him in a calm, nonconfrontational tone. Resident #6 had diagnoses including non-Alzheimer's dementia, anxiety, depression, and psychotic disorder, with a BIMS score of 05/15 and use of antianxiety, antidepressant, and antipsychotic medications. The care plan addressed mood alterations related to depression, anxiety, and dementia but did not identify nonpharmacological interventions, and progress notes and behavior monitoring records did not document them despite observed behaviors. Resident #7 had diagnoses including anxiety, depression, and PTSD, with a BIMS score of 15/15 and use of antidepressant and antipsychotic medications. The care plan addressed mood alterations but did not identify nonpharmacological interventions, and progress notes and behavior monitoring records again lacked documentation of such interventions. The facility policy stated non-pharmacological approaches must be attempted unless clinically contraindicated, and the DON stated staff should have implemented and documented them.
Expired anticonvulsant medication administered
Penalty
Summary
The facility failed to identify an expired anticonvulsant medication before it was administered to Resident #17. Resident #17 had a BIMS score of 13 out of 15, indicating intact cognition, and diagnoses that included multiple sclerosis, seizure disorder, and respiratory failure. The resident required setup assistance with eating and oral hygiene, moderate assistance with other ADLs and mobility, and had a recent MDS indicating receipt of an anticonvulsant medication during the look-back period. The MAR showed a physician’s order for a 200 mg anticonvulsant medication by mouth twice daily, and the care plan directed staff to administer the medication as ordered. During a medication observation, Staff I, a CMA, was preparing to administer the anticonvulsant medication when the medication card was found to have five pills remaining and two labels. One label showed the medication had been received on a prior date and directed staff to reorder after a specified date, while the other label showed an expiration date of 10/2024. Staff I stated she would remove the medication from the resident’s stock and use the replacement from the e-kit, and the ADON stated the medication had just been received from the supply pharmacy and needed to be replaced. The facility policy on Medication Administration directed staff to identify the expiration date and notify the nurse manager if the medication was expired. The DON stated staff should have checked the expiration date before administration and, if expired, destroy and replace it through the pharmacy.
Failure to Follow Physician Orders and Protocols for Constipation Management
Penalty
Summary
The facility failed to follow physician-ordered interventions for two residents who experienced extended periods without a bowel movement. For one resident with a diagnosis of constipation and always incontinent of bowel, electronic health records showed multiple episodes of three or more days without a bowel movement. Although there was a physician's order for milk of magnesia to be given as needed for constipation, medication administration records indicated it was not consistently administered according to the order, and there was a lack of documentation for administration during some periods. The resident's care plan required documentation of bowel movements every shift and adherence to facility protocol for stool softeners, laxatives, or enemas, but these interventions were not consistently followed or documented. For another resident with moderate cognitive impairment and multiple diagnoses, including malnutrition and a history of falls, records showed a gap of three days without a bowel movement. The resident had several as-needed orders for constipation management, including milk of magnesia, Miralax, and bisacodyl suppository, with instructions to escalate interventions if no bowel movement occurred for several days. However, medication administration records showed these interventions were only given on two occasions during the month, and progress notes indicated refusals without documentation of any assessment related to constipation. There was also a lack of abdominal assessments or documentation of change in condition in the resident's records. Interviews with nursing staff and administration revealed inconsistencies in following the bowel protocol and confusion regarding the use of bowel movement reports generated from the electronic health record system. Staff acknowledged that the bowel report was not functioning correctly, leading to missed identification of residents with prolonged periods without a bowel movement. Additionally, the facility lacked a formal bowel protocol policy, a policy for when assessments should be completed, and a medication administration policy, contributing to the failure to provide appropriate treatment and care as ordered.
Failure to Follow Infection Control Practices During Catheter Care
Penalty
Summary
Staff failed to follow appropriate infection prevention and control practices while providing personal and catheter care to a resident on Enhanced Barrier Precautions (EBP). During the observed care, staff performed hand hygiene and donned gloves and gowns initially, but did not change gloves or perform hand hygiene after removing the lift cloth and before proceeding to cleanse the resident's meatus and catheter tubing. Additionally, after handling the catheter and emptying urine, staff did not consistently cleanse the catheter tip as required, and did not remove gloves and gowns or perform hand hygiene before leaving the resident's room. One staff member walked through common areas and hallways wearing contaminated gloves and gown, carrying used equipment, before removing personal protective equipment and performing hand hygiene in the utility room. The resident involved was nonverbal, had an indwelling catheter, and was always incontinent of bowel, as documented in the Minimum Data Set. Facility policy required hand hygiene before and after handling invasive devices, after removing gloves, and before leaving isolation precaution settings. The Director of Nursing confirmed that the observed practices did not meet facility expectations or policy requirements for infection prevention and control, particularly regarding hand hygiene, glove and gown removal, and proper cleansing of catheter equipment.
Facility Fails to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to provide access to personal funds managed by the facility for a resident, as required by their policy. The resident, who had no cognitive impairment, expressed a desire to access her personal funds on a weekend to purchase soda but was unable to do so because the funds were not accessible during weekends or evenings. The facility's policy stated that residents should have access to funds of $100 or less within 24 hours, but this was not adhered to. The Business Office Manager, who along with the Administrator, was the only staff with access to the petty cash, confirmed that residents could not access their funds outside of her working hours, which were Monday through Friday, 8:00 AM to 4:30 or 5:00 PM. The Administrator acknowledged that residents did not have access to their funds during weekends or evenings unless they were contacted to come in, which had not occurred. This lack of access was corroborated by a CNA who stated that residents could not get money from the resident trust during these times.
Failure to Serve Correct Portion Sizes for Mechanical Soft Diet
Penalty
Summary
The facility failed to adhere to the prescribed menu and portion control guidelines for residents on a mechanical soft diet. During an observation, it was noted that Staff H processed 8 meatballs for residents requiring a mechanical soft diet and placed them in a plastic container on the steam table. However, when serving the last plate, Staff H measured only 1/3 cup of the remaining meatballs, which was not in accordance with the documented requirement of 2 ground meatballs per serving for mechanical soft diets. Staff I, the Certified Dietary Manager, and Staff E, the Contract Registered Dietitian, both acknowledged that all processed mechanical soft meatballs should have been served, and there should not have been any leftovers. The facility's undated policy on portion control specifies that food should be served according to standard portion sizes to ensure adequate servings and equal portions for residents. The failure to serve the correct portion size resulted in a deficiency in meeting the nutritional needs of 4 out of 24 residents reviewed.
Failure to Maintain Safe Food Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature during a lunch service, as observed on 2/26/25. Staff H, the AM Cook, served the last plate for a resident on a mechanical soft diet and recorded a temperature of 95 degrees for the remaining mechanical soft meatballs in the steam table. This temperature was acknowledged as unacceptable by Staff H, who stated that the food should have been held at a temperature of 135 degrees or higher. Staff I, the Certified Dietary Manager, and Staff E, the Contract Registered Dietitian, both confirmed that the mechanical soft meatballs should have been maintained at a holding temperature of 135 degrees or higher. The facility's undated policy on food temperatures documented that hot food temperatures must read no less than 140 degrees when residents are served.
Deficiency in Food Storage and Thermometer Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitation, as observed during a survey. Containers of cut lettuce, tomatoes, turkey gravy, bread stuffing, and cut ham were found in a refrigerator with dates indicating they had been stored beyond the facility's policy of discarding open food after three days. Additionally, a plastic bag of ham and a pitcher of lemonade were dated well beyond this timeframe, and other drink pitchers were undated. Staff I, the Certified Dietary Manager, acknowledged that these items should have been disposed of according to the facility's expectations. Furthermore, the facility did not sanitize a thermometer before rechecking the temperature of mechanical soft meatballs, which were being reheated in a microwave. Staff I used the thermometer multiple times without cleaning it between uses, which was against the facility's policy. Staff E, a Contract Registered Dietitian, confirmed that food should have been discarded after three days and that the thermometer should have been sanitized before use. The facility's policy, revised in July 2014, required all foods stored in the refrigerator or freezer to be covered, labeled, and dated with a use-by date.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility staff failed to report suspected abuse involving a resident and a staff member within the required two-hour timeframe. On February 23, 2025, Staff K, a Certified Nurse Aide (CNA), witnessed another CNA, Staff L, inappropriately tickling a resident's nipple while assisting the resident with dressing. Despite observing this behavior at 12:30 PM, Staff K did not report the incident to the Assistant Director of Nursing (ADON) until after 3:10 PM, which was beyond the two-hour reporting requirement. The ADON was notified at 3:40 PM and subsequently informed the Administrator at 3:45 PM. The facility's policy mandates that all allegations of resident abuse must be reported immediately to the Administrator and to the appropriate state entity within two hours. Staff K had completed a valid Dependent Adult Abuse training in March 2022, indicating awareness of the reporting requirements. However, the delay in reporting the incident was a clear violation of the facility's abuse prevention and reporting policy. The Director of Nursing confirmed that the ADON was the on-call leadership staff on the day of the incident, and the Administrator acknowledged that the staff should have reported the incident immediately after it was observed.
Deficiencies in Comprehensive Care Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents, leading to deficiencies in their care. Resident #16, who has severe cognitive impairment and multiple diagnoses including dementia and hypertension, was ordered oxygen therapy as needed. However, the care plan lacked documentation related to respiratory compromise and did not include goals or interventions for oxygen use. Staff interviews revealed inconsistencies in the monitoring and understanding of the resident's oxygen needs, with some staff unaware of when the resident used oxygen. The Assistant Director of Nursing acknowledged that the care plan should have included detailed instructions for oxygen use, but it was not up to date. Resident #5, who has multiple complex medical conditions including cerebral palsy and quadriplegia, required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The care plan for this resident did not include any focus, goals, or interventions for restorative, physical, or occupational therapy, nor for repositioning. Staff interviews indicated that the resident was not repositioned regularly, and the Director of Nursing admitted that the care plan lacked necessary details for positioning. A system error had caused the restorative program to be removed from the electronic health record, and the Director of Nursing and Administrator acknowledged this oversight. The facility's policies on restorative nursing services, repositioning, and comprehensive person-centered care plans emphasize the need for individualized care plans with measurable objectives. However, these policies were not followed for the two residents in question, resulting in incomplete care plans that did not address their specific needs. The Director of Nursing and Administrator recognized the deficiencies and the need for corrective action, but the report does not detail any specific steps taken to address the issues at the time of the survey.
Care Plan Deficiencies in Resident Interventions and Family Involvement
Penalty
Summary
The facility failed to review and revise the care plan interventions for three residents, leading to deficiencies in their care. Resident #12, who had normal cognition and required assistance for certain activities, was not updated in the care plan after the discontinuation of the walk to dine restorative nursing program. Despite the program being discontinued, the care plan still included an intervention for walking to meals, which was not updated to reflect the resident's current needs. Resident #19, with moderate cognitive impairment and a history of smoking, had a care plan that did not include updated interventions from a smoking assessment. The care plan failed to reflect the need for a smoker's apron and supervised smoking, as indicated in the smoking data collection. This oversight was acknowledged by the staff, who admitted that the care plans might not be up to date and that the interventions from assessments should be included. Resident #2, with severe cognitive impairment, had a care plan conference that did not include the resident's Power of Attorney (POA), despite documentation stating otherwise. The POA was not invited to the care conference, and the staff member responsible for notifying family members admitted to not documenting who was present at the meetings. The Director of Nursing acknowledged that care plan conferences were not being completed appropriately and emphasized the importance of accurate documentation and family involvement.
Failure to Provide Restorative Care for Resident with Contractures
Penalty
Summary
The facility failed to provide necessary restorative care to a resident, identified as Resident #5, to maintain or improve their range of motion. The resident's Minimum Data Set (MDS) indicated multiple medical conditions, including athetoid cerebral palsy, contractures in various body parts, and unspecified quadriplegia. Despite these conditions, the resident's care plan lacked focus, goals, or interventions for restorative, physical, or occupational therapy. The resident's electronic health records (EHR) showed no orders for restorative therapy or orthotic devices, such as palm protectors or carrot hand orthosis, which were recommended by occupational therapy to prevent further contractures and skin breakdown. The deficiency was further compounded by a system error that led to the restorative program being removed from the EHR in September 2024, as acknowledged by the Director of Nursing (DON) and the Administrator. The Certified Occupational Therapy Assistant (COTA) confirmed that the resident had been on occupational therapy from June to July 2024, with a short-term goal of trialing orthotic splints. However, the resident was discharged from occupational therapy upon being transferred to the hospital, with no progress reported in their range of motion. The facility's policy on restorative nursing services emphasized individualized and resident-centered care, which was not reflected in the resident's care plan or treatment records.
Failure to Maintain Nutritional Status
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, resulting in an 11.05% weight loss over six months. The resident, who had moderately impaired cognition and multiple diagnoses including diabetes mellitus and Alzheimer's Disease, was observed not being awakened for meals and seeking food outside of scheduled meal times. The care plan directed staff to monitor and report signs of malnutrition and to provide a regular diet with thin liquids, but these directives were not effectively followed. The Registered Dietitian (RD) was not informed that the resident was not being awakened for meals, which would have prompted further action. Staff members, including Certified Nursing Aides and the Certified Medication Aide, were unaware of the resident's significant weight loss and did not document meal refusals. The Electronic Health Record did not include documented breakfast responses, indicating a lack of proper monitoring and documentation. The facility's policy required assistance with meals to meet individual needs, but this was not adhered to, contributing to the resident's nutritional decline.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 7.14% during a medication administration observation. Staff F, a Certified Medication Aide, administered medications to a resident, including Oxycodone/APAP, Miralax, gabapentin, celecoxib, citalopram, azathioprine, Lisinopril, Omeprazole, a multivitamin, vitamin C, and an Ocuvite gummy. However, discrepancies were noted in the administration of Omeprazole and vitamin C. The resident received Omeprazole 40 mg instead of the prescribed 20 mg, and vitamin C 500 mg instead of the prescribed 1000 mg. The resident involved had a history of memory problems, severely impaired decision-making ability, and diagnoses including diabetes mellitus, anxiety disorder, immunodeficiency, Alzheimer's Disease, and dementia. The resident's care plan included a 1000 mg vitamin C order to promote wound healing for an unstageable pressure ulcer. The errors were attributed to incorrect entries in the Electronic Health Record (EHR) and a lack of verification against the Medication Administration Record (MAR). The Assistant Director of Nursing confirmed the Omeprazole order was incorrectly entered, and the Director of Nursing noted that staff should have clarified the order with the physician.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention practices during the care of a resident, identified as Resident #5, who required complex medical interventions including an enteral tube, tracheostomy tube, and a suprapubic catheter. During an observation of tracheostomy care performed by an LPN, it was noted that the LPN did not perform hand hygiene after removing gloves following the initial removal of the tracheal appliance, which was against the facility's policy. The Director of Nursing (DON) acknowledged this lapse in hand hygiene, which was expected to be completed with all glove changes. Additionally, during personal care provided by two CNAs to the same resident, there were missed opportunities for hand hygiene. The CNAs did not perform hand hygiene and change gloves when moving from the peri area to the suprapubic catheter stoma, from the catheter stoma to the buttocks, and before applying barrier cream. The DON confirmed that hand hygiene and glove changes should have been conducted at these points, as per the facility's hand hygiene policy.
Failure to Provide Adequate ADL Assistance and Repositioning
Penalty
Summary
The facility failed to provide adequate care for a resident who required assistance with activities of daily living (ADLs). The resident, who had multiple medical conditions including athetoid cerebral palsy, contractures, and quadriplegia, was documented as rarely or never understood and required the use of an enteral tube, tracheostomy tube, and a suprapubic catheter. The care plan indicated that the resident needed assistance from two people for bathing twice a week and repositioning every two hours to prevent skin breakdown and promote comfort. However, staff interviews revealed that the resident was not repositioned regularly and was left lying on their back with only stuffed animals for support, despite grimacing when repositioned. The Director of Nursing (DON) and other staff members believed that the air flow mattress provided sufficient pressure relief, negating the need for repositioning. Additionally, the facility failed to provide the resident with the expected number of baths. The bathing records showed that the resident received only one bath per week for three out of four weeks, missing scheduled baths on several occasions. The DON acknowledged that the facility's expectation was for the resident to receive two baths per week, and that missed baths should have been made up. The facility's policies on repositioning and ADLs emphasized the importance of individualized care plans to prevent skin breakdown and maintain or improve residents' abilities to perform ADLs, but these were not adhered to in the case of this resident.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
