Lyon Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Rock Rapids, Iowa.
- Location
- 1010 South Union, Rock Rapids, Iowa 51246
- CMS Provider Number
- 165215
- Inspections on file
- 18
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Lyon Specialty Care during CMS and state inspections, most recent first.
A resident with dementia, anxiety disorder, muscle weakness, and moderate cognitive impairment was reportedly yelled at and had their lips forcibly held shut for several seconds by a CNA after the resident was yelling out. An LPN at the nurse’s station heard the CNA tell the resident to be quiet and saw the CNA’s hand move away from the resident’s face, and another CNA later reported witnessing the physical contact. The allegation was not communicated in a manner that ensured prompt administrative awareness, and the DON did not learn of the incident until the following day, after the CNA had completed one full shift and worked part of another. As a result, the facility’s self-report to the state survey agency was made more than 2 hours after the allegation was initially made, contrary to the facility’s abuse policy requiring immediate internal reporting and notification to the state within 2 hours.
A resident with dementia, anxiety, muscle weakness, and severe cognitive impairment was being pushed in a wheelchair while yelling out, which staff described as normal for him. An LPN at the nurses’ station heard a CNA tell the resident to “shut the fuck up” and saw the CNA’s hand move away from the resident’s face but did not intervene or separate them. Another CNA later reported that she had seen the same CNA pinch the resident’s lips closed for several seconds while again telling him to “shut the fuck up,” and that the resident was then assisted to bed. Although facility policy required immediate measures to prevent further potential abuse, including separating an employee accused of abuse from residents, the alleged abusive CNA continued working the rest of the shift and returned for the next shift before any separation occurred.
A resident with dementia, anxiety disorder, and muscle weakness, and a BIMS score indicating severe cognitive impairment, was allegedly told to shut up and be quiet and had their lips pinched by a CNA while being assisted to their room, as reported by another CNA and partially overheard by an LPN. However, no documentation of this alleged abuse incident was entered into the resident’s progress notes, and no incident report was found. The facility also lacked a policy on maintaining accurate and complete resident records, resulting in the resident’s medical record not reflecting the reported event.
The facility failed to serve full portions of food as per the menu, leading to a deficiency in meeting residents' nutritional needs. On a specified date, mixed vegetables were substituted with wax beans, and a staff member did not provide correct portions, serving a resident approximately 1/4 scoop of beans and another resident 1/2 scoop of ground turkey. The facility's policy outlines procedures for accurate food measurements, but these were not followed, resulting in the deficiency.
A facility failed to provide a bed hold notice to a resident or their representative before a planned therapeutic leave. The resident, with diagnoses including a pelvic mass and muscle weakness, was taken to the Mayo Clinic for testing and returned after two days. The facility's policy requires written information about bed-hold rights and limitations to be given before a transfer, but this was not done. The administrator confirmed the oversight, acknowledging the expectation for staff to complete such notices.
A resident, dependent on staff for transfers and diagnosed with dementia and traumatic brain dysfunction, was involved in an incident where CNAs failed to lock wheelchair brakes during a mechanical lift transfer. This action was against the facility's policy, as confirmed by the DON.
A CNA failed to follow proper infection control practices during incontinence care for a resident. The CNA did not change gloves or perform hand hygiene after touching a trash can and soiled catheter tubing, continuing care with soiled gloves. The facility's policies on hand hygiene and glove use were not adhered to, as confirmed by the DON.
Failure to Timely Report Alleged Verbal and Physical Abuse to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. Resident #1 had diagnoses of non-Alzheimer’s dementia, anxiety disorder, and muscle weakness, with a BIMS score of 8 indicating moderate cognitive impairment. According to staff statements, Resident #1 was being assisted in a wheelchair to his room when he was yelling out, which staff described as normal for him. Staff B, a CNA, reported that Staff D, a CNA, came from behind the nurse’s station, grabbed the resident’s lips together with her thumb and index finger for approximately five seconds, and told him to “shut the fuck up.” Staff A, an LPN, did not witness the pinch but heard what was said to the resident and saw Staff D’s hand moving away from the resident’s face. Staff A documented the concern and left a note for the DON, then later messaged the DON the following evening asking if the note had been received. The DON was not working that day and did not become aware of the allegation until approximately 5:00 p.m. the following day, at which time she contacted Staff A and learned of the alleged incident. The DON confirmed that Staff D completed her full shift on the day of the alleged incident and worked again the following day before the DON became aware of the situation. Facility intake information showed the self-report to DIAL was submitted the evening after the DON learned of the allegation, which was more than 2 hours after the initial allegation was made to Staff A. Facility policy required that all allegations of abuse be reported immediately to the charge nurse, that the charge nurse immediately notify the Administrator or designee, and that all allegations be reported to the Iowa Department of Inspections and Appeals no later than 2 hours after the allegation is made.
Failure to Immediately Separate Resident from Alleged Abusive Staff Member
Penalty
Summary
The deficiency involves the facility’s failure to immediately separate a vulnerable resident from a staff member following an alleged abuse incident. Resident #1 had diagnoses of non-Alzheimer’s dementia, anxiety disorder, and muscle weakness, with a BIMS score of 8 indicating severe cognitive impairment. On the evening of 12/22/25, Staff C was pushing Resident #1 in a wheelchair past the nurses’ station while the resident was yelling out, which staff described as normal for him. Staff A, an LPN, was at the nurses’ station charting when she heard Staff D, a CNA, tell the resident to “shut the fuck up.” Staff A looked up, verbally responded “really” to Staff D, and observed Staff D’s hand moving away from the resident’s face, but did not witness any physical contact. Staff A did not intervene to separate the resident from Staff D and did not assist with putting the resident to bed. Later that evening, after the shift ended, Staff B, a CNA, sent a message to Staff A reporting that she had seen Staff D walk out from behind the nurses’ station, pinch the resident’s lips closed with her thumb and index finger for approximately five seconds, and again tell him to “shut the fuck up” while Staff C continued to assist the resident to bed. Staff B stated that the resident’s yelling out was normal for him and that Staff A was present at the nurses’ station when this occurred. The facility’s Dependent Adult Abuse policy, dated November 2019, required that upon receiving a report of an allegation of resident abuse, the facility immediately implement measures to prevent further potential abuse, including separating the accused employee from all residents by suspension or reassignment. Despite this policy, the alleged abusive staff member continued to work the remainder of the shift on 12/22/25 and returned for the next shift before any separation occurred, and the Administrator later acknowledged the facility should have separated the staff member from others at the time of the incident.
Failure to Document Alleged Abuse Incident in Resident Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records regarding an alleged abuse incident involving one resident. The resident had diagnoses including non-Alzheimer’s dementia, anxiety disorder, and muscle weakness, with a BIMS score of 8 indicating severe cognitive impairment. According to a written statement by an LPN (Staff A), a CNA (Staff B) reported that two CNAs (Staff C and Staff D) were assisting the resident to his room when the resident was talking and Staff D told him to shut up and be quiet. Staff B further reported that she saw Staff D pinch the resident’s lips together. Staff A did not witness the pinch but stated she heard what was said to the resident and, when she looked up from her charting, she saw Staff D’s hand moving away from the resident’s face. Despite this alleged incident, review of the resident’s progress notes showed no documentation of the event that occurred on that date. The facility had submitted a self-report of an allegation of abuse, but there was no corresponding entry in the resident’s medical record describing the incident. Additionally, the facility did not have a policy on maintaining accurate and complete resident records. A regional nurse consultant confirmed there was nothing charted in the resident’s record regarding the incident and that there was no incident report of any type, demonstrating the lack of required documentation for this event.
Deficiency in Food Portioning and Menu Adherence
Penalty
Summary
The facility failed to serve the full portions of food as outlined in their menu, which led to a deficiency in meeting the nutritional needs of residents. On the specified date, the facility's menu for both regular and mechanical diets included an open-faced turkey sandwich, mashed potatoes, turkey gravy, mixed vegetables, and melon. However, during meal service, mixed vegetables were substituted with wax beans, and the staff member responsible for serving the meals did not provide the correct portions. Specifically, Resident #30 received approximately 1/4 scoop of beans instead of the planned 1/2 cup, and Resident #1 received approximately 1/2 scoop of ground turkey instead of the full portion. Additionally, the staff member failed to properly fill and empty the scoop when serving wax beans, resulting in inconsistent portion sizes. The facility's Kitchen Weights and Measures policy, last revised in April 2007, outlines the training and procedures for ensuring accurate food measurements and portion sizes. Despite this policy, the staff member did not adhere to the guidelines, leading to the deficiency. The Dietary Manager confirmed the expectation for staff to serve correct portions using the appropriate utensils, emphasizing the importance of proper nutrition for residents. The failure to serve the correct portions and the substitution of menu items without proper adjustments contributed to the deficiency identified by the surveyors.
Failure to Provide Bed Hold Notice for Therapeutic Leave
Penalty
Summary
The facility failed to provide a bed hold notice to Resident #33 or their representative prior to the resident's departure for a planned therapeutic leave. This deficiency was identified through a review of clinical records, staff interviews, and facility policy. Resident #33, who had diagnoses including a pelvic mass, pulmonary nodule, and muscle weakness, was taken by family to the Mayo Clinic for testing and returned to the facility after two days. The facility's policy, dated March 2017, requires that residents and their representatives receive written information about bed-hold rights and limitations, payment policies, and transfer details before a transfer occurs. However, upon review of the clinical chart on July 23, 2024, it was found that the facility did not issue a bed hold notice for Resident #33's therapeutic leave from March 28 to March 30, 2024. The facility's administrator confirmed in an interview on July 24, 2024, that the staff failed to complete the required bed hold notice for the resident's leave. The administrator acknowledged the expectation that staff should complete a bed hold notice whenever residents leave the facility for therapeutic leave.
Failure to Lock Wheelchair Brakes During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the proper use of a mechanical lift, leading to a deficiency in preventing accidents and hazards for a resident. The Minimum Data Set (MDS) assessment for the resident did not document a Brief Interview for Mental Status (BIMS) score, but indicated the resident was dependent on staff for care and transfers, with diagnoses including dementia, traumatic brain dysfunction, and altered mental status. The care plan had initiated the use of a mechanical lift for transfers. During an observation, two Certified Nurse's Aides (CNAs) used a mechanical lift to transfer the resident from the bed to a wheelchair but failed to lock the wheelchair brakes before lowering the resident, contrary to the facility's policy. The Director of Nursing confirmed the requirement to lock the wheelchair brakes during such transfers.
Infection Control Breach During Incontinence Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during incontinence care for a resident. During an observation, a Certified Nursing Assistant (CNA), referred to as Staff A, was seen performing perineal care on a resident. While doing so, Staff A used their left gloved hand to take a trash can from another CNA, Staff B, and placed it on the floor. Despite touching the trash can, Staff A did not change gloves or perform hand hygiene before continuing with the perineal care. Staff A then took a clean wipe from Staff B and continued the care with the same soiled gloves. Further observations revealed that Staff A touched the soiled catheter tubing and leg strap on the resident's leg without changing gloves or performing hand hygiene, and continued with the perineal care. After completing the care, Staff A used the same soiled gloves to clean the catheter tubing. Only after completing all tasks did Staff A and Staff B remove their gloves and perform hand hygiene. The facility's policies on hand hygiene and glove use, which emphasize the importance of hand hygiene in preventing infection spread, were not followed. The Director of Nursing confirmed that the staff was expected to change gloves and perform hand hygiene after the gloves became soiled.
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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