Montezuma Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Montezuma, Iowa.
- Location
- 316 Meadow Lane Drive, Montezuma, Iowa 50171
- CMS Provider Number
- 165295
- Inspections on file
- 18
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Montezuma Specialty Care during CMS and state inspections, most recent first.
Kitchen sanitation was not maintained in 2 of 2 observations. Cabinets, drawers, and cupboards contained heavy crumbs, food debris, dust, splatters, black debris, a dead winged insect, and what appeared to be a black human hair. The DM stated staff were expected to wipe down drawers and cupboards and guessed they had not been cleaned recently, although they were supposed to be cleaned daily.
Care plan failed to reflect a resident’s exit-seeking behavior and related window tampering. The resident had dementia, bipolar disorder, depression, and moderately impaired cognition, and records showed repeated statements about wanting to leave, including attempts to remove screws from the window and screen so she could get out. Despite these documented behaviors, the care plan did not include the resident’s desire to leave or her history of removing parts of the window.
Failure to administer oxygen in accordance with the physician order occurred for a resident on continuous O2 therapy. The resident, who had an irregular heartbeat and intact cognition, was observed with portable O2 that was not delivering oxygen because the tank valve was not connected correctly; the resident was unaware the tank was not working, and the DON later found the O2 saturation was 91%. Staff reported that the CNA had set up the portable O2, while the RN stated nurses regulate and administer O2.
A resident with atrial fibrillation and a dislocated knee had apixaban ordered to be held before orthopedic surgery, but the anticoagulant was still administered instead of being withheld. Staff later discovered the error, notified the surgical team, and the surgery was postponed. Interviews confirmed confusion about the hold order and that the medication was not properly removed from the med cart.
The facility failed to treat residents with dignity and respect, affecting four residents. A CNA yelled at residents during a dining incident and made inappropriate comments, contrary to care plans. One resident felt bad after being told his falls were recurring, and another was avoided by the CNA for weeks after an incident. The facility's policy on dignity and respect was not followed, and reported concerns were not adequately addressed.
The facility failed to address concerns about staff treatment of residents, involving incidents where a CNA yelled at residents and avoided providing care. Despite reports and written statements from staff, there was no documentation of follow-up by the administration. The facility's policy on dignity and respect was not upheld, affecting residents with varying cognitive conditions.
The facility failed to conduct effective QAPI activities, lacking documentation and structured processes to address quality deficiencies related to resident treatment and dignity concerns. From January to October, there was no evidence of ongoing QAPI program activities, monitoring, or evaluation of corrective actions. The facility's policy outlined the QAPI committee's responsibilities, but the Administrator admitted that past citations had not been discussed in QA meetings.
A resident with multiple health conditions, including risk for pressure injuries, did not receive the prescribed double protein diet as ordered. Despite the care plan and dietary instructions, observations showed meals lacking the required protein portions. Interviews with dietary staff revealed a failure to implement the diet order correctly.
A resident with a history of mobility issues and a recent fracture was observed being pushed in a wheelchair with only one foot pedal, contrary to safety expectations. The CNA acknowledged the missing pedal, and the ADON confirmed the requirement for both pedals for safe transport. The resident expressed frustration over the missing pedal since admission.
The facility failed to treat two residents with dignity by not assisting them with the bedpan and instructing them to urinate or defecate in their incontinent briefs. Multiple staff members confirmed the residents' complaints, but the facility's grievance log did not contain any records of these issues. The staff member involved has been suspended pending investigation.
A facility failed to report and investigate an allegation of abuse where a staff member instructed a resident to urinate and defecate in her brief instead of assisting her with a bedpan. Multiple staff members were aware of the incident but did not document or investigate it properly, leading to a deficiency in compliance with federal requirements.
A resident with a tibia fracture reported that a night shift staff member instructed her to urinate and defecate in her incontinent brief instead of providing a bedpan. This was corroborated by another resident and multiple staff members, but the facility failed to document and investigate the allegations properly, violating their abuse prevention and dignity policies.
The facility failed to create interventions based on root cause analysis of falls to prevent future falls for a resident with severe cognitive impairment and a history of falls. Despite multiple documented falls resulting in injuries, the resident's care plan lacked specific interventions, and the clinical record did not show any analysis or preventive measures.
Kitchen sanitation not maintained
Penalty
Summary
The facility failed to maintain adequate kitchen sanitation in 2 of 2 kitchen observations. During an observation on 4/21/2026 at 10:29 a.m., small plates and dishes were found face down in a cupboard covered with heavy crumbs, and cabinets on the left side and back wall of the kitchen were sticky to the touch and partially covered with red and dark colored splatters and food debris. Styrofoam plates sat in a cupboard on a coating of heavy dust, and multiple drawers and cupboards contained serving scoops, slotted serving spoons, ladles, muffin tins, cookie sheets, pans, and other kitchen tools sitting in layers of crumbs, food debris, red droplets, black debris, and what appeared to be a black human hair. A small, dead, winged insect was also observed on the floor of one cupboard near the cookie sheets. Multiple pitchers were stored on bare wood in a cupboard below the coffee maker, and the wood was stained black. On 4/22/2026 at 9:50 a.m., the drawers and cupboards remained unchanged from the prior observation. The facility policy Sanitation, revised October 2008, stated staff would maintain a clean and sanitary food service area and clean surfaces such as shelves frequently enough to prevent the accumulation of grime. On 4/23/26 at 9:20 a.m., the Dietary Manager stated she expected staff to wipe down drawers and cupboards and said she guessed they had not been cleaned recently, adding that they were supposed to be cleaned daily.
Care Plan Not Updated for Exit-Seeking Behavior
Penalty
Summary
The facility failed to update Resident #6’s care plan to reflect exit-seeking behavior and related unsafe actions. The resident’s MDS dated 12/19/25 listed diagnoses of non-Alzheimer’s dementia, bipolar disorder, and depression, and identified a BIMS score of 11 out of 15, indicating moderately impaired cognition. The facility policy stated that care plans would incorporate risk factors associated with identified problems. Clinical documentation showed repeated statements and behaviors related to wanting to leave the facility. An 8/8/25 encounter note stated the resident expressed a strong desire to leave the care facility. A 2/17/26 nurses note stated the resident told a family member she tried to remove the window in her room so she could get out, and inspection found she had removed a screw from the window track to open the window fully. A 3/2/26 encounter note stated the family reported the resident’s cognition was worsening and that she had recently removed screws from the screen in her room because she wanted to try to climb out her window. On 4/20/26, the resident again stated she wanted to be released from the facility and said she wanted to leave and maybe would just go out the window. As of 4/21/26, the care plan did not include her desire to leave the facility or her history of removing a part of the window.
Failure to Administer Portable Oxygen Correctly
Penalty
Summary
Facility staff failed to administer oxygen in accordance with physician orders for one resident who had a diagnosis of an irregular heart beat and was identified in the MDS as receiving continuous oxygen therapy. The resident had intact cognition with a BIMS score of 15 out of 15. During an observation, the resident was sitting in a recliner with the oxygen tubing in her nose and the concentrator set at 1 liter, and she was seen taking deep breaths while relaxing. During a later observation, the resident was in the dining room for breakfast and the portable oxygen tank level indicator was not in the red area, which indicated an inadequate to no supply of oxygen. The resident was unaware that the tank was not administering oxygen. When the DON assessed the resident, the oxygen saturation was 91%. The Administrator checked the portable oxygen tank and stated it looked pressurized. Staff C, a CMA, used an O2 key to open the portable tank, but the key was not lined up correctly with the valve, causing oxygen to release around the connection with a high hissing sound. The DON then demonstrated the correct connection and, once properly connected, oxygen was delivered through the meter and tubing cannula to the resident's nose. Staff C stated she had put the portable oxygen on and turned it to 1 liter, and Staff A, an RN, stated the CNA had not brought any residents who used portable oxygen to her and that nurses regulate and administer oxygen.
Failure to Hold Anticoagulant Before Scheduled Surgery
Penalty
Summary
Ensure that residents are free from significant medication errors. The facility failed to hold apixaban, an anticoagulant, as ordered for a resident with atrial fibrillation and a dislocated right knee with a bone fragment concerning for fracture. The resident had an orthopedic surgery scheduled for the right knee, and the orthopedic surgeon documented that the blood thinner had to be stopped five days before surgery or anesthesia could not be given. The medication administration record showed apixaban was ordered to be held from 4/19/26 to 4/21/26, but the medication was still administered on the morning of 4/19/26 and continued twice daily. Progress notes showed the surgery was scheduled for 4/22/26 and later staff documented confusion about the hold order and the surgery date. A pharmacist requested a note to hold the blood thinner for 3 days prior to surgery, and on 4/21/26 staff discovered the resident had received the morning dose on 4/20/26 and that the evening dose from 4/19/26 was not in the medication card. Staff notified the surgical team, and the surgery was rescheduled for 4/27/26. Interviews with nursing staff and the DON confirmed the medication error occurred, that the hold order had been entered into the computer, and that the resident’s blood thinner was not properly removed from the medication cart or held as intended.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, affecting four out of twelve residents reviewed. Resident #8, with intact cognition, was directed to be spoken to face-to-face to reduce confusion due to schizophrenia. However, Staff F was reported to have yelled at her during a dining incident, telling her that the conversation was none of her business. Resident #12, with moderately impaired cognition, was directed to receive positive interaction due to her emotional state. Staff F also yelled at her during the same dining incident. Resident #11, who had intact cognition and was diagnosed with depression, anxiety, and paraplegia, reported feeling bad after Staff F commented on his recurring falls. This interaction was contrary to the care plan, which directed staff to speak to him calmly. Additionally, Resident #6, with intact cognition and requiring assistance for bed mobility, reported that Staff F accused her of resisting during care and subsequently avoided her room for three weeks, leaving her care to other staff. The facility's policy on Residents Rights-Dignity and Respect was not adhered to, as evidenced by multiple staff statements and resident interviews. Staff D reported that Staff F yelled at residents and made inappropriate comments, which were documented and submitted to the Administrator but not addressed. The Administrator acknowledged the lack of additional documentation related to grievances or staff concerns, indicating a failure to investigate and address the reported issues adequately.
Failure to Address Staff Misconduct and Resident Dignity Concerns
Penalty
Summary
The facility administration failed to address concerns regarding staff treatment of residents, specifically involving four residents. Resident #8, with intact cognition, was directed to have consistent routines to reduce confusion, yet experienced an incident where Staff F yelled at her during dinner. Resident #12, with moderately impaired cognition, was directed to receive positive interactions, but was also yelled at by Staff F. Resident #11, with intact cognition and paraplegia, was made to feel bad by Staff F after a fall, as Staff F commented on the recurring nature of the falls. Resident #6, with intact cognition and requiring assistance for bed mobility, reported that Staff F accused her of resisting care and subsequently avoided her room for three weeks. The facility's policy on Residents Rights-Dignity and Respect, which mandates respectful and considerate care, was not adhered to in these instances. Written statements from Staff D CNA detailed multiple incidents where Staff F displayed inappropriate behavior, such as yelling at residents and making derogatory comments. Despite these reports, there was a lack of documentation indicating that the administration followed up on these concerns, and Staff D's written statements placed in the Administrator's mailbox did not receive a response. Interviews with various staff members revealed that Staff F's behavior was known among the staff, and there was an awareness of his reluctance to care for Resident #6. The former DON acknowledged awareness of the situation with Resident #6 but could not recall other concerns about Staff F. The Administrator admitted to not having additional documentation related to grievances or staff concerns and stated that the way Staff F spoke to residents was unacceptable.
Lack of Effective QAPI Activities
Penalty
Summary
The facility failed to conduct effective Quality Assurance and Performance Improvement (QAPI) activities, as evidenced by a lack of documentation and structured processes to address quality deficiencies related to resident treatment and dignity concerns. The review of QAPI/QA documentation from January to October revealed an absence of evidence for ongoing QAPI program activities in these areas. The facility did not document any monitoring or evaluation of the effectiveness of corrective actions or performance improvement activities, nor did it revise these activities as needed. The facility's policy on QAPI Program Governance and Leadership, revised in March 2020, outlined the responsibilities of the QAPI committee to identify and resolve negative outcomes and coordinate performance improvement projects. However, the Administrator admitted that since his tenure, past citations had not been discussed in QA meetings.
Failure to Provide Prescribed Double Protein Diet
Penalty
Summary
The facility failed to provide the diet as ordered for a resident reviewed for nutrition. The resident, who had a diagnosis of hyponatremia, COPD, pulmonary embolism, and osteoarthritis, was at risk for pressure injuries and was on a therapeutic diet. The care plan directed staff to provide double protein twice a day, but the resident reported receiving a large amount of starches instead. The resident also mentioned receiving foods high in vitamin K, which she needed to avoid due to being on a blood thinner. Observations confirmed that the resident's meals lacked the prescribed double protein portions. On two separate occasions, the resident received only a single protein source at lunch. Interviews with dietary staff revealed a misunderstanding or failure to implement the diet order correctly, as the dietary manager and registered dietitian both acknowledged the requirement for double protein but did not ensure it was provided. The registered dietitian reviewed the diet order and menu but did not rectify the issue before the surveyor's observation.
Deficiency in Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair, leading to a deficiency. Resident #18, who has intact cognition and a history of arthritis, osteoporosis, a cerebrovascular accident, and a fractured right humerus, was observed being pushed in a wheelchair by a Certified Nursing Assistant (CNA) with only one foot pedal. The resident's care plan indicated the need for a wheelchair for mobility and assistance due to a recent fracture, with a non-weight-bearing restriction on the right upper extremity. During the observation, the CNA expressed a wish to find the missing wheelchair pedal and instructed the resident to keep their feet up. The Assistant Director of Nursing (ADON) confirmed that the expectation is for both foot pedals to be present for safety when pushing a wheelchair. The resident reported having only one pedal since arriving at the facility, which was upsetting. The facility's assessment identified the resident's mobility issues and the need for proper transfer equipment, including a wheelchair.
Failure to Assist Residents with Toileting and Maintain Dignity
Penalty
Summary
The facility failed to treat two residents with dignity by not assisting them with the bedpan and instructing them to urinate or defecate in their incontinent briefs. Resident #5, who had a tibia fracture and required substantial assistance for toileting, reported that a night shift staff member repeatedly told her to defecate in her brief instead of providing a bedpan. This made Resident #5 feel dirty and humiliated. Resident #6, who was present during the incident, corroborated Resident #5's account and stated that the staff member, identified as Staff A, made similar comments on two separate occasions. Resident #3 also reported hearing Staff A instruct another resident, Resident #11, to urinate in her pants about a year ago. Resident #11 required extensive assistance for toileting due to limited mobility from a hip fracture. Multiple staff members, including CNAs and an RN, confirmed that Resident #5 had reported the issue to them, and they had escalated the concern to the former Director of Nursing (DON) and the Assistant Director of Nursing (ADON). However, the facility's grievance log did not contain any records of these complaints. The former DON stated that she had educated Staff A about ensuring residents were not wet but did not recall being informed about the specific issue of instructing residents to soil themselves. The current Administrator only became aware of the situation recently and suspended Staff A pending an investigation. The facility's policy on dignity, revised in February 2021, emphasized that staff should care for residents in a manner that promotes their well-being and self-esteem.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving a staff member who allegedly instructed a resident to urinate and defecate in her incontinent brief instead of assisting her with a bedpan. Resident #5, who had a tibia fracture and required substantial assistance for toileting, reported that a night shift staff member repeatedly told her to go in her brief and even reached into her brief to check if she was wet enough. This incident was corroborated by Resident #6, who was Resident #5's roommate and witnessed the staff member's behavior on two separate occasions. Despite multiple staff members, including CNAs and an RN, being aware of the incident and reporting it to higher authorities such as the former Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the facility failed to document or investigate the complaint properly. The facility's grievance log did not contain any concerns related to the incident, and the former DON claimed she was unaware of the specific allegations. The Administrator only became aware of the situation after the survey team initiated their investigation. The facility's policy on abuse, neglect, and exploitation, which mandates the identification, investigation, and reporting of all possible incidents, was not followed. The policy also emphasizes the importance of maintaining a culture of compassion and caring for all residents, which was evidently not upheld in this case. The failure to report and investigate the abuse allegation promptly led to a deficiency in the facility's compliance with federal requirements for resident care and safety.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse and ensure protection from further abuse for a resident. Resident #5, who had a tibia fracture and required substantial assistance for toileting, reported that a night shift staff member instructed her to urinate and defecate in her incontinent brief instead of providing a bedpan. This incident was corroborated by Resident #6, who witnessed the staff member's actions on two separate occasions. Despite these reports, the facility's grievance log did not contain any concerns related to this issue, indicating a failure to document and investigate the allegations properly. Multiple staff members, including CNAs and an RN, confirmed that Resident #5 had reported the abuse to them, and they had relayed the information to the former Director of Nursing (DON) and the Assistant Director of Nursing (ADON). However, the former DON stated she did not recall receiving such a report and would have investigated it if she had. The ADON also confirmed that she had reported the incident to the former DON after being informed by the residents during her rounds. The facility's policy on abuse prevention and dignity required the identification, investigation, and reporting of all possible incidents of abuse, neglect, and mistreatment. However, the facility failed to adhere to these policies, as evidenced by the lack of documentation and investigation into the reported abuse. The Administrator only became aware of the situation after the survey team began their investigation, leading to the suspension of the implicated staff member and the initiation of an investigation.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to create interventions based on root cause analysis of falls to prevent future falls for a resident with a history of falls and severe cognitive impairment. The resident, who had diagnoses including pelvic fracture, non-Alzheimer's dementia, and heart failure, was dependent on staff for transfers and had a history of falls resulting in injuries such as fractures and lacerations. Despite multiple falls documented in incident reports, the resident's care plan lacked specific interventions to address the falls, and the clinical record did not show any facility analysis of the root causes of each fall or interventions implemented to prevent future falls. The facility's policies on assessing falls and managing fall risks required identifying possible causes of falls and implementing specific interventions to prevent them. However, observations and staff interviews revealed that the facility did not adhere to these policies for the resident in question. The Director of Nursing acknowledged that the lack of care plan interventions for the resident was not in line with the facility's expectations, indicating a failure to follow established protocols for fall prevention.
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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