Mount Ayr Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Ayr, Iowa.
- Location
- 1504 East South Street, Mount Ayr, Iowa 50854
- CMS Provider Number
- 165224
- Inspections on file
- 18
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Mount Ayr Health Care Center during CMS and state inspections, most recent first.
Food service safety practices were not followed during kitchen storage and meal service. The Cook's Refrigerator had an incomplete temp log with missing entries, the upright freezer contained a milky white frozen substance and crumbs, and a Dietary Aide donned gloves without hand hygiene and used the same gloved hand to touch pie slices and dessert dishes while serving pie. The Food Service Supervisor and Administrator acknowledged the incomplete logs, unclean freezer condition, and improper food handling.
Failure to notify the LTC Ombudsman of two resident moves: one resident with moderately impaired cognition was sent to the hospital after a fall and returned shortly after, and another resident with intact cognition was discharged home with family. The facility's transfer/discharge form did not show Ombudsman notification for either event, and the Administrator said one was missed because the stay away was brief and the other because it occurred on a weekend.
A resident with anxiety, depression, and mild intellectual disability later developed a new diagnosis of delusional disorder/paranoid delusions, with MDSs and the care plan documenting psychotic/behavioral symptoms and ongoing use of antipsychotic, antianxiety, and antidepressant meds. The facility’s most recent PASRR remained the one completed earlier, and the DON and Administrator acknowledged that a new PASRR should have been completed when the new mental health diagnosis was added.
An LPN left an EHR laptop open on a medication cart in the lobby on two occasions, allowing two residents' medication lists to remain visible when she walked away. One resident was wandering nearby during one of the incidents. The facility policy required resident records to be kept confidential and secure, and the DON stated staff should have locked the laptop screen before leaving the cart.
Failure to perform hand hygiene and change gloves during catheter care. A CNA transferred a resident with an indwelling urinary catheter, then used the same gloves to handle the urine measuring cylinder and access the catheter drainage spigot without hand hygiene or a glove change. The resident had moderately impaired cognition, multiple diagnoses including BPH, kidney failure, and neurogenic bladder, and required extensive assistance with ADLs and mobility.
A Certified Dietary Manager did not follow proper hand hygiene and glove use protocols while preparing raw pork chops, handling non-food items and food without changing gloves or washing hands as required by facility policy.
Four residents were not offered the recommended pneumococcal vaccine, as required by CDC guidelines and facility policy. Vaccine records showed that these individuals had neither received nor refused the vaccine, and staff interviews confirmed that the omission was due to a focus on COVID-19 and influenza vaccinations, with no documented rationale for not addressing pneumococcal immunization.
The facility did not fully develop or implement comprehensive, individualized care plans for three residents with complex behavioral and mental health needs. One resident's care plan interventions, such as weekly social service visits and activity invitations, were not consistently documented or carried out. Two other residents receiving psychotropic medications had care plans that lacked specific target behaviors and non-pharmacological interventions, despite documented incidents of disruptive and inappropriate behaviors. Staff interviews confirmed these omissions, and facility policy required individualized, resident-centered care planning.
A resident with diabetes experienced a critically low blood sugar reading, but staff did not provide timely intervention or document a follow-up assessment. Despite facility policy and staff knowledge that interventions and rechecks were required, no action was taken or recorded after the low reading, and the resident did not receive a snack until hours later.
The facility failed to update its infection control policy since 2020 and did not maintain proper infection control practices during catheter care for a resident with renal insufficiency. A CNA was observed touching contaminated surfaces with gloved hands before performing catheter care, contrary to facility policy. The DON confirmed the lapse in procedure adherence.
The facility failed to include two residents in their care plan conferences, despite documentation indicating their attendance. Interviews revealed inconsistencies in care conference practices, with staff initially stating residents and families do not attend, later claiming they are invited but choose not to. The facility lacks a formal care conference policy, contributing to the deficiency.
Food Service Safety Lapses During Storage and Meal Service
Penalty
Summary
The facility failed to prepare, serve, and distribute food in accordance with food service safety practices during mealtime service. During an initial kitchen observation, the Cook's Refrigerator had an incomplete temperature log with missing entries for 4/8 and 4/10/26. The bottom of the upright freezer contained a milky white frozen substance and crumbs across the bottom, and the freezer held a 5-gallon container of ice cream on the top shelf with frozen meats on the bottom shelf. The Food Service Supervisor stated the temperature logs were expected to be completed as required and acknowledged that the melted ice cream on the bottom of the freezer should have been cleaned up. The Administrator also concurred that cleaning of kitchen appliances and logging of temperatures needed to be completed. During meal service, Staff D, Dietary Aide, donned gloves without hand hygiene and used the right hand to cut pie and load slices onto a pie server. Using the left gloved hand, Staff D obtained dessert plates, placed them on the counter, and touched the pie slices while moving them from the pie server onto dessert plates and a dessert bowl. This process continued for 16 pieces of pie, with Staff D touching both the dessert dishes and the pie slices with the same gloved hand before removing gloves and washing hands. The Food Service Supervisor stated that pie should be served with a pie server and fork and that staff should not touch the pie with gloved or non-gloved hands. The facility's policy stated hand washing should occur before and after glove use, gloves should be changed when touching contaminated surfaces and after interruptions, and refrigeration temperatures should be taken and recorded daily.
Failure to Notify Ombudsman of Resident Transfers and Discharge
Penalty
Summary
The facility failed to notify the Long-Term Care State Ombudsman of two resident transfers, including one hospital transfer and one discharge home. Resident #13 had a BIMS score of 12 out of 15, indicating moderately impaired cognition, and diagnoses that included high blood pressure, coronary artery disease, diabetes mellitus, thyroid disorder, and non-Alzheimer's dementia. After a fall, the resident was transferred to the hospital for evaluation and then returned to the facility shortly afterward, but the Notice of Transfer Form to the Long-Term Care Ombudsman did not document Ombudsman notification for that hospital transfer. Resident #28 had a BIMS score of 15 out of 15 and diagnoses of diabetes mellitus and hypothyroidism. The resident was discharged home with family on the planned discharge date, but the Notice of Transfer Form to the Long-Term Care Ombudsman did not document Ombudsman notification for the discharge. The Administrator stated he was not aware Resident #13's transfer required Ombudsman notification because of the short time away from the facility, and he overlooked Resident #28's discharge notification because it occurred on a weekend day. The facility policy stated it was responsible for notifying the long term care ombudsman monthly of transfers to the hospital and discharges that may occur.
Failure to Complete PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a PASRR for one resident who developed a new mental disorder diagnosis after admission. The resident had been admitted with existing diagnoses of generalized anxiety disorder, major depressive disorder, and mild intellectual disability, and the most recent PASRR on file from 12/29/21 identified major depression, anxiety disorder, and mental retardation with no current mental health symptoms and no Level II required at that time. The resident’s clinical record later documented a new diagnosis of delusional disorder/paranoid delusions during the stay, along with ongoing use of antipsychotic, antianxiety, and antidepressant medications. The resident’s MDS assessments documented diagnoses including anxiety disorder, depression, and psychotic disorder, with one assessment noting other behavioral symptoms not directed toward others for 1 to 3 days over the prior 14 days. The care plan identified behavioral problems due to delusional disorder and paranoia, and physician orders included aripiprazole, clonazepam, and sertraline for the resident’s psychiatric conditions. During interview, the DON acknowledged that the most recent PASRR was from 12/29/21 and that a new PASRR should have been completed when the additional diagnosis of delusions was added. The Administrator also acknowledged that a new PASRR should have been completed with the new mental health diagnosis.
Resident Information Left Visible on Open EHR Laptop
Penalty
Summary
The facility failed to properly protect resident information from unauthorized access when an LPN left an EHR laptop open on the medication cart in the lobby on two separate occasions. On 4/11/26 at 11:44 AM, the LPN walked away from the cart to get a cup for a resident, and Resident #16's medication list was visible on the screen while Resident #6 was continuously wandering around the lobby. The LPN returned at 11:46 AM and stated she usually closes the laptop but thought the task would be completed quickly. Later that same day at 11:57 AM, the LPN again walked away from the medication cart to administer medications to a resident in the dining room, and Resident #10's medication list was visible on the screen. The facility's Securing Resident Records Policy dated 9/12/25 stated that resident records, including electronic records, must be kept confidential and secure, and that all staff are responsible for protecting resident information from unauthorized access, use, or disclosure at all times. On 4/13/26, the DON stated staff should have locked the laptop screen before leaving the medication cart.
Failure to Perform Hand Hygiene and Glove Change During Catheter Care
Penalty
Summary
The facility failed to implement infection control practices when Staff B, a CNA, manipulated Resident #1’s urinary catheter drainage spigot with gloves that had already been used during the resident’s transfer from a wheelchair to a recliner. Resident #1 had a BIMS score of 9 out of 15, indicating moderately impaired cognition, and diagnoses included cancer, BPH, kidney failure, and neurogenic bladder. The resident required extensive assistance with ADLs and mobility and had an indwelling urinary catheter in place. During continuous observation, Staff B and Staff C transferred the resident using a mechanical lift. After the resident was seated, Staff B used the same gloves to handle the urine measuring cylinder, raise the resident’s pant leg, unscrew the catheter drainage bag spigot, and empty urine into the cylinder, then into the toilet. Hand hygiene and a glove change were not performed during the process. Staff C stated Staff B should have performed hand hygiene and changed gloves before accessing the urinary drainage bag, and Staff B stated she did not believe hand hygiene or a glove change was needed. The DON later stated staff should have performed hand hygiene and changed gloves prior to accessing the drainage bag.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
A Certified Dietary Manager (CDM) failed to maintain sanitary practices in the kitchen by not performing hand hygiene between handling non-food items and raw food. During observations, the CDM was seen opening packages of raw pork chops, using a can of cooking spray and a bottle of olive oil blend with a gloved hand, and then handling raw pork chops with both gloved and ungloved hands without changing gloves or washing hands. The CDM repeated this process multiple times and later stated she believed touching raw food with bare hands was permitted, acknowledging she did not perform hand hygiene or change gloves after handling non-food items. Facility policy required employees to wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident, as well as to use gloves for direct food contact and wash hands before donning and after removing gloves.
Failure to Offer Pneumococcal Vaccine to Eligible Residents
Penalty
Summary
The facility failed to offer the recommended pneumococcal vaccine to four out of eight residents reviewed for vaccines, despite CDC guidelines and facility policy requiring such vaccinations. Clinical record reviews showed that these residents had neither received nor refused the appropriate pneumococcal vaccine, and there was no documentation of any rationale for not offering the vaccine. The residents involved were all of advanced age, as indicated by their dates of birth, and their electronic health records did not reflect any action regarding the pneumococcal vaccine. Interviews with facility staff revealed that the issue was not addressed by physicians, and there was no explanation for why the vaccine was not offered. The Assistant Director of Nursing stated that the facility's focus had been on COVID-19 and influenza vaccinations, leading to the oversight. The Administrator acknowledged that staff should have used an interdisciplinary approach to identify residents eligible for vaccinations, as required by both CDC guidance and facility policy.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to follow and fully develop comprehensive, resident-centered care plans for three residents. For one resident with intact cognition and diagnoses including anxiety disorder, depression, neurocognitive disorder with Lewy bodies, and borderline personality disorder, the care plan included interventions such as behavioral health consults and weekly social service visits. However, documentation revealed that these weekly visits were not consistently documented, and the social services designee admitted to not recording refusals or all visits. The resident reported that visits were infrequent and often occurred incidentally during housekeeping, rather than as planned, sit-down visits. Staff observations confirmed the resident spent most of her time in bed with the lights off, and staff did not consistently invite her to participate in group activities as outlined in her care plan. For a second resident with severe cognitive impairment and a history of behavioral symptoms, the care plan included administration of antipsychotic and antidepressant medications but failed to specify target behaviors for these medications. Progress notes documented multiple incidents of sexual inappropriateness, combativeness, and disruptive behaviors, including inappropriate touching of staff, yelling, cursing, and physical aggression. Despite these documented behaviors, the care plan did not address or include interventions for these specific behaviors, nor did it provide guidance for staff on how to manage them. A third resident with severe cognitive impairment and diagnoses of chronic kidney disease, dementia, anxiety, depression, and insomnia was prescribed multiple psychotropic medications. The care plan referenced the use of these medications but did not include individualized target behaviors for staff to monitor or non-pharmacological interventions to attempt if behaviors were observed. Staff interviews confirmed that the care plan lacked this information, and the facility's policy required care plans to be individualized and comprehensive, incorporating behavioral and emotional health needs. The failure to individualize and fully implement care plans for these residents constituted the deficiency.
Failure to Provide Follow-Up for Critically Low Blood Sugar
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate follow-up assessment and intervention for a diabetic resident who experienced a critically low blood sugar (BS) result of 30 mg/dL. The resident, who had intact cognition and multiple diagnoses including diabetes mellitus, peripheral vascular disease, and paraplegia, reported a recent episode of low blood sugar. Clinical records showed that on the day of the incident, the resident's BS was recorded as 30 mg/dL by the facility's glucometer and 57 mg/dL by the resident's own meter. Despite this, there was no documentation of any intervention, such as providing carbohydrates or quick-acting sugar, nor was there evidence of a follow-up BS check or further progress notes for that day. Interviews with staff confirmed that the facility lacked a specific protocol for identifying and managing low blood sugar events, and that interventions and follow-up checks should have been documented. The resident did not receive a snack until several hours after the low BS reading, and there was no evidence that staff followed the care plan or the American Diabetes Association's guidelines for hypoglycemia. The Director of Nursing acknowledged that staff should have intervened and rechecked the BS within 30 minutes, but this was not done.
Infection Control Policy and Practice Deficiencies
Penalty
Summary
The facility failed to update its infection control policy and maintain proper infection control practices, specifically in the care of a resident with an indwelling catheter. The infection control policy was last reviewed on April 8, 2020, and had not been updated since, despite the facility's practice of annual reviews. The Director of Nursing (DON) and the Administrator acknowledged that the policies were reviewed annually but lacked signatures to confirm recent reviews. This oversight in policy updating was identified during a survey, highlighting a lapse in administrative procedures. Additionally, the facility did not adhere to proper infection control practices during catheter care for a resident diagnosed with renal insufficiency. During an observation, a Certified Nurse Aide (CNA) was seen touching contaminated surfaces with gloved hands before performing catheter care, which is against the facility's policy. The policy requires staff to wash hands, apply clean gloves, and avoid touching contaminated surfaces before providing catheter care. The DON confirmed the observation and acknowledged the expectation for staff to use clean gloves prior to emptying the catheter, indicating a failure in following established infection control procedures.
Failure to Include Residents in Care Plan Conferences
Penalty
Summary
The facility failed to include two residents in their care plan participation conferences, despite documentation indicating their attendance. Resident #4, who has no cognitive impairment, stated she had never been invited to or attended a care conference, contradicting the Care Plan Conference Note that documented her attendance. Similarly, Resident #12, with mild cognitive impairment, expressed uncertainty about attending any care plan conferences, despite documentation stating otherwise. Interviews with staff revealed inconsistencies in the facility's care conference practices. Staff B initially stated that residents and families do not attend care conferences, which are held for staff only, but later claimed residents are invited but choose not to attend. The Activity Director confirmed that residents are not present at their care conferences, and the Director of Nursing acknowledged that the team does not meet with residents and the entire care plan team simultaneously. Additionally, the facility lacks a formal care conference policy, contributing to the deficiency.
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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