Northbrook Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Rapids, Iowa.
- Location
- 6420 Council Street Ne, Cedar Rapids, Iowa 52402
- CMS Provider Number
- 165587
- Inspections on file
- 33
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Northbrook Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with intact cognition, ADL self-care deficits, and dependence on staff for ambulation and transfers did not receive the ordered restorative ROM program recommended by therapy. Although therapy issued recommendations for active ROM exercises to the lower extremities and nursing notes indicated that restorative referrals were received and that the resident was "continuing" a restorative program, there was no documentation that the specific exercises were carried out. Staff interviews revealed that therapy referrals to restorative were not effectively communicated, the restorative aide reported never receiving a PT referral and confirmed the resident did not receive restorative services, and nursing leadership acknowledged a lapse in administering the restorative program over an extended period, contrary to the facility’s restorative nursing policy.
The facility failed to respond promptly to resident call lights, as reported by multiple cognitively intact residents. One resident stated that call light responses often exceeded fifteen minutes and that she also used her call light for a roommate unable to call independently. Another resident, who required two-person assistance for transfers and toileting, reported daily delays in call light response on any shift, sometimes up to an hour, leading to incontinence. A third resident on O2 via nasal cannula reported call light response times over thirty minutes and up to an hour, and described staff turning off the call light and leaving without providing assistance or returning, despite his need for help with ambulation when unsteady. Resident Council notes documented ongoing concerns about long call light response times, and leadership acknowledged that such concerns were being tracked through council reports.
Two residents received medications intended for others after staff failed to properly identify them, with one receiving another's insulin and requiring ER observation, and another receiving a full set of morning medications meant for a different resident, leading to abnormal blood pressure readings. Both incidents involved staff relying on verbal or visual cues rather than following identification protocols.
A resident with cognitive and mobility impairments was not assisted respectfully or promptly by an RN when requesting help to find a bathroom, resulting in the resident being left unattended and partially exposed while attempting self-transfer. Additionally, confidential health information was left visible and unattended on a laptop in two hallways, contrary to facility policy and staff expectations regarding privacy.
Multiple residents with significant care needs experienced prolonged waits for staff assistance, with call lights often unanswered for extended periods. This led to incontinence accidents and falls, as staff—including CNAs, RNs, and the DON—were observed not responding to call lights in a timely manner. Staff interviews confirmed that inadequate staffing contributed to these delays, and facility policy requiring prompt response was not consistently followed.
The facility failed to ensure a clean, safe, and comfortable environment by not adequately cleaning and repairing toilets, leaving beds unmade, and failing to replace or repair damaged window screens and loose electrical outlets. Multiple residents experienced persistent odors, unclean bathrooms, and unresolved maintenance issues, with staff confirming delays and inconsistencies in cleaning and repairs.
Staff failed to maintain resident dignity and respect by not keeping a resident's wheelchair clean despite repeated concerns, using inappropriate language about a resident in public, and posting signs in a resident's room about toileting without consulting the resident. These actions affected residents with severe cognitive impairment and mobility issues, and did not align with facility policies on dignity and individualized care.
A resident readmitted after severe medical conditions did not receive required physical assessments or consistent documentation of vital signs over several days. Despite ongoing health issues and facility policy mandating assessments and vitals every shift, staff failed to document these, and leadership confirmed the absence of records in the electronic health record.
Three residents were affected by the facility's failure to use foot pedals during wheelchair transport and to maintain mobility equipment in safe working order. One resident was pushed in a wheelchair without foot pedals, causing her feet to touch the ground, while another was transported without pedals due to their inconvenience at the dining table. A third resident fell when his walker, which was in poor condition with missing screws, collapsed during a transfer. Staff interviews confirmed recurring issues with missing foot pedals and inadequate equipment checks.
The facility failed to maintain a clean and homelike environment, with multiple resident rooms having window curtains falling down or missing, and exterior windows covered in dust and grime. A resident expressed dissatisfaction with the dirty windows, and the Housekeeping Supervisor cited staff shortages and acknowledged the issues, noting that exterior windows were last cleaned in the fall.
A resident with severe cognitive impairment was physically abused by a CNA, who struck the resident on the back of the head. The incident was witnessed by a CMA and reported to the charge nurse immediately. The facility's policy mandates investigation and reporting of abuse, but the incident was not addressed promptly, resulting in a deficiency.
The facility failed to maintain a sanitary environment during dining and wound care, leading to potential infection risks. A CNA did not sanitize hands between assisting residents with meals, and food trays were transported uncovered through a COVID-positive hallway. Additionally, a nurse did not perform hand hygiene between glove changes during wound care. These actions violated the facility's infection control program, which emphasizes handwashing before and after resident contact.
The facility failed to maintain the dignity of two residents. One resident was brought to the dining room without pants, covered only by a blanket, and the issue was not promptly addressed. Another resident, requiring extensive assistance, was left exposed during personal care, and staff did not offer hand hygiene after the resident scratched herself. The DON acknowledged the care did not meet expectations, highlighting a lapse in maintaining resident dignity.
A resident with no cognitive impairment was excluded from decision-making regarding their dietary needs, despite expressing dissatisfaction with a ground meat diet and requesting a reevaluation. The facility relied on a Durable Power of Healthcare document to direct decisions to the family, assuming the resident was unable to make decisions, which was not the case. Delays in a speech evaluation were due to insurance and co-pay issues.
A facility failed to update a resident's Care Plan to include monitoring for an antidepressant prescribed months earlier. The resident, with severe cognitive impairment and multiple diagnoses, was prescribed Remeron, but the Care Plan lacked focus, goals, or interventions related to the medication. The oversight was acknowledged by the ADON, MDS coordinator, and DON, who realized the medication was not added to the TAR for monitoring until months later.
A resident with ESRD on dialysis did not receive meals according to their prescribed renal diet, which required double protein servings and avoidance of high sodium foods. The resident reported receiving inappropriate meals, such as sauerkraut and sausage gravy, and smaller portions of eggs than ordered. The dietician confirmed these discrepancies, acknowledging the failure to provide the correct menu alternatives.
A facility failed to conduct required pre and post dialysis assessments for a resident with ESRD, despite the care plan indicating the need for such assessments. The resident, who was cognitively intact, could not recall any pattern of assessments, and a review confirmed their absence in records. The DON acknowledged the lack of these assessments.
A facility failed to notify the LTC Ombudsman of a resident's transfer to the hospital, as required by federal regulation. The resident was hospitalized for several days, and the deficiency was identified during a clinical record review and staff interview. The Administrator confirmed the lack of notification and acknowledged the expectation to notify the Ombudsman, although the facility did not have a specific policy in place.
A facility failed to notify a resident and their representative of the bed hold policy during two hospitalizations. The resident was discharged and reentered the facility twice, but there was no documentation of notification regarding the bed hold policy. The Administrator acknowledged the oversight, stating that a bed hold should be completed and explained to the resident or their representative. The facility's policy requires informing the resident or legal representative of the bed hold policy upon admission and prior to, or as soon as possible, after transfer or temporary discharge.
A resident with a history of polio and falls was transferred without the required assistance of two staff members, resulting in a fall from a mechanical lift. The incident was not immediately assessed by a nurse, and the facility lacked proper documentation and notification. The resident experienced increased pain, and staff interviews revealed inconsistencies in reporting the incident.
A facility failed to complete a quarterly MDS assessment on time for a resident with moderate cognitive impairment and multiple diagnoses, including acute respiratory failure and congestive heart failure. The assessment was overdue by 9 days, and the DON was unaware of the delay. The facility lacked a written policy for resident assessments and care planning.
A resident received Glimepiride for 77 days without a diabetes diagnosis or physician's order due to a nurse's error in entering another resident's order into the EHR. The error went unnoticed by multiple staff, including nurses, CMAs, the DON, and pharmacy consultants, leading to the resident's hospitalization for hypoglycemia. Staff interviews revealed a lack of procedures for verifying medication orders against diagnoses.
The facility failed to provide consistent restorative care for three residents, leading to a decline in mobility and range of motion. A resident with hemiplegia lacked a documented plan for range of motion activities, and their family expressed concerns about care practices. Another resident with cognitive impairment was unaware of any restorative program, and a third resident reported not being offered range of motion services. The facility lacked a restorative plan, policy, or procedure to maintain residents' functioning.
A resident with moderate cognitive impairment and no history of diabetes was incorrectly administered Glimepiride, leading to hypoglycemia. The error was not identified during three provider visits in June, despite medication reviews. The facility lacked a written policy for medication errors, and the issue was only addressed after the resident was hospitalized.
A resident with moderate cognitive impairment and no diabetes diagnosis received 77 doses of Glimepiride due to a failure in the pharmacy consultant's medication review process. The error was discovered after the resident was hospitalized for hypoglycemia, and the facility lacked a policy for addressing medication errors.
A resident with severe cognitive impairment and requiring extensive assistance for transfers fell and injured her wrist due to inadequate supervision and failure to use a gait belt as per the care plan. The CNA assisting the resident was new and unaware of the resident's needs, leading to the incident.
The facility failed to provide the required two baths weekly for four out of five residents reviewed, with some residents receiving no baths for an entire month. The issue was partly due to an increase in the facility's census and the recent addition of a designated bath aide.
The facility failed to provide appropriate assessments and interventions for residents with impaired skin and changes in condition. One resident with heart disease and Alzheimer's did not receive weekly skin assessments for over two months. Another resident with cancer and renal insufficiency had soiled dressings and extensive edema without follow-up orders or assessments. Two other residents with pressure injuries did not receive weekly assessments as required by the facility's policy.
The facility failed to follow the care plan for a resident with cognitive impairments and a history of pressure ulcers. The resident was left seated in a wheelchair for an extended period without repositioning or incontinence care, contrary to the care plan's directives. Staff interviews confirmed the lack of adherence to the care plan and facility policies for skin care and pressure ulcer prevention.
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. One resident did not receive prescribed antifungal creams, another had inconsistent application of Triad paste for a pressure ulcer, and a third did not receive Silvadene ointment as ordered. These failures resulted in inadequate treatment and documentation of the residents' conditions.
Failure to Implement Ordered Restorative ROM Program
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing services as recommended by the therapy department to maintain or improve a resident’s range of motion and mobility. The resident had intact cognition, required partial to moderate assistance with dressing and hygiene, and was dependent on staff for ambulation and transfers. The MDS assessment indicated that the resident did not receive therapy or restorative services during the seven days prior to the assessment, despite having care plan interventions directing staff to encourage participation in exercise and physical activity for strengthening and improved mobility. The clinical record showed multiple physician orders for PT and OT evaluations and treatment over several months, and a therapy recommendation dated 12/19/2025 for restorative staff to administer active ROM exercises to the resident’s bilateral lower extremities one to five times per week. Nursing progress notes documented that therapy recommendations for a restorative exercise program were received on 12/4/2025 and again on 12/23/2025, with copies reportedly provided to the rehab aide for scheduling. Notes from a CNA/restorative aide on 12/6/2025 and 12/26/2025 stated that the resident continued with a restorative program and that there were no concerns, but there was no documentation that the specific recommended ROM exercises were actually implemented or performed. Interviews revealed discrepancies and gaps in carrying out the restorative program. The DON reported that the resident had a foot pedal machine in her room that she used when she allowed staff to get her up, and that therapy typically wrote restorative programs that the facility followed, but acknowledged that the facility failed to administer the resident’s therapy from mid-December through February. The occupational therapy aide stated that after therapy services ended in early December and January, therapy made a referral to restorative for a home program and later recommended lower extremity exercises when the resident admitted not using the pedal machine. The restorative aide reported having no referral from PT for this resident and confirmed the resident did not receive restorative services, while the LPN overseeing therapy acknowledged reviewing the restorative recommendation and her prior note but confirmed that the restorative aide denied receiving a copy. This sequence of events demonstrates that the interdisciplinary team did not ensure the restorative program was implemented as recommended, contrary to the facility’s Restorative Nursing Program Policy.
Failure to Respond to Resident Call Lights in a Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to consistently respond to resident call lights in a timely manner, despite the requirement to provide sufficient nursing staff each day and have a licensed nurse in charge on each shift. Record review showed that three residents with intact cognitive status reported prolonged call light response times. One resident, seated in the dining room with a walker nearby, stated that call light responses often took more than fifteen minutes and that she also activated the call light for her roommate, who was unable to call for assistance independently. Another resident, who required the assistance of two staff members for transfers and toileting, reported that staff failed to answer his call light in a timely manner at least once a day on any shift, and that he had personally timed responses taking up to an hour, which resulted in episodes of incontinence. A third resident, observed in a recliner with oxygen via nasal cannula and a walker nearby, reported that staff were slow to respond to his call light, with response times sometimes exceeding thirty minutes and up to an hour based on his own timing. He also reported that staff at times entered his room in response to the call light, turned the light off, left without providing the requested assistance, and did not return. This resident required staff assistance to ambulate when feeling unsteady. Resident Council meeting notes documented that call lights taking too long had been raised as an ongoing concern under Old Business. During an interview, the DON and Administrator acknowledged that when Resident Council reports identify call light concerns, the facility addresses them through audits and staff education and reviews the concern at subsequent Resident Council meetings.
Medication Administration Errors Due to Resident Misidentification
Penalty
Summary
The facility failed to administer medications as ordered for two residents, resulting in each receiving another resident's medications. In the first incident, a resident with diagnoses including acute kidney failure, Type 2 diabetes, and schizophrenia, and who was cognitively intact, was given another resident's insulin doses. The error occurred when an agency LPN, while administering morning insulins, relied on a CNA's identification of the resident, which was based on a visual cue (a red blanket) rather than proper identification protocols. The resident responded affirmatively to the wrong name when called, and the LPN administered both long-acting and short-acting insulin intended for another resident. The error was discovered when the LPN noticed a different name tag on the resident's door. The resident was subsequently sent to the emergency room for observation due to the risk of hypoglycemia, though she was asymptomatic at the time of transfer. In the second incident, another resident with a history of hypertension, septicemia, aphasia, and stroke, and with moderately impaired cognition, was administered a full set of morning medications intended for a different resident. The error was made by an Oral Medication Technician (OMT) who was unfamiliar with both residents, as they were new to the facility and had similar names. The OMT administered the medications after the resident answered affirmatively to the wrong name. The error was realized when the OMT saw the correct name outside the door after leaving the room. The resident received medications including antihypertensives and diuretics, and subsequent blood pressure monitoring showed several low diastolic readings, though no immediate side effects were observed by staff. Both incidents involved failures to properly identify residents before medication administration, despite facility policy requiring the use of two identifiers and positive identification before giving medications. In both cases, staff relied on verbal confirmation or visual cues rather than following established procedures for resident identification. These failures resulted in residents receiving medications not intended for them, necessitating additional monitoring and medical intervention.
Failure to Ensure Resident Dignity and Privacy
Penalty
Summary
The facility failed to respond respectfully and promptly to a resident's request for assistance with toileting, and did not protect residents' right to privacy regarding electronic health information. A resident with intact cognition, a history of Alzheimer's disease, stroke, cancer, and recent falls, who required staff assistance for toileting, asked a registered nurse for help locating the bathroom. The nurse informed the resident that the bathroom was in her room, questioned her presence in the hallway, and then sought assistance from another staff member who was not employed at the facility. The nurse stated she could not help due to being occupied with treatments and walked away, leaving the resident unattended. Shortly after, the resident was observed alone in her room, attempting to transfer from her wheelchair to the bed with her pants and incontinence underwear partially pulled up, exposing her upper buttocks, and the bathroom door open. Additionally, the facility did not safeguard residents' confidential health information. On two separate occasions, a treatment cart with a laptop displaying a resident's picture and confidential health information was left unattended and unlocked in residential hallways. Staff, including registered nurses, left the computer screens visible and unattended while out of sight, despite the facility's policy and staff interviews confirming the expectation to lock computer screens when not in use to protect privacy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The facility failed to provide timely responses to resident call lights, resulting in unmet care needs for seven out of nine residents reviewed. Multiple observations and interviews revealed that call lights were not answered within the facility's expected timeframe of 10-15 minutes, with some residents waiting up to an hour. Staff, including CNAs, RNs, and the DON, were observed walking past active call lights without responding, and residents reported frequent delays in receiving assistance, particularly for toileting and mobility needs. Several residents with significant physical and cognitive impairments, such as hemiplegia, hemiparesis, muscle weakness, and severe cognitive impairment, were affected by these delays. Residents described waiting extended periods for help with toileting, resulting in incontinence accidents and, in some cases, falls when attempting to manage their needs independently. Documentation confirmed that some residents experienced repeated falls and accidents directly related to delayed staff response to call lights. Staff interviews corroborated the residents' accounts, with CNAs and RNs acknowledging that all staff were responsible for answering call lights but citing insufficient staffing levels as a barrier to timely responses. The facility's policy required prompt attention to call lights and for staff to remain with residents if unable to immediately meet their needs, but this was not consistently followed. The deficiency was substantiated through direct observation, resident and staff interviews, and review of facility policies and care plans.
Failure to Maintain Sanitary and Safe Resident Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Toilets in several resident rooms were not adequately cleaned, with persistent urine odors, wet floors, and visible fecal matter remaining for days. In one case, a resident's wheelchair and cushion were not cleaned regularly, resulting in a strong urine odor that was noticed by family members. Housekeeping staff reported that bathrooms were scheduled for cleaning only on certain days, and there was confusion about who was responsible for reporting and addressing maintenance issues, such as a running and overflowing toilet that was not reported to maintenance or administration. Beds in some rooms were found unmade or only partially made, with bare mattresses or missing blankets and bedspreads. Additionally, window screens were found to be broken or missing for extended periods, with residents reporting that screens had been damaged by housekeeping staff and not replaced for months. Housekeeping and maintenance staff confirmed ongoing issues with cleaning schedules and the replacement of window screens, and documentation showed that some windows had not been cleaned or screens replaced for several months. Electrical safety was also compromised, as one resident reported loose wall outlets that had not been repaired despite being reported to the Maintenance Director months prior. Observations confirmed that plugs for essential medical equipment, such as a CPAP machine, were hanging loosely from the outlets. Staff interviews revealed that there was only one housekeeper on certain weekends, leading to delays in cleaning, and that complaints from residents about cleanliness were known but not always addressed promptly. Facility policies required daily cleaning of toilets, but this was not consistently followed.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Facility staff failed to treat residents with dignity and respect in several instances. For one resident with severe cognitive impairment and limited mobility, staff did not maintain the cleanliness of his wheelchair as required by his care plan. The wheelchair and its cushion were observed to have a strong urine odor, visible crumbs, and stains, and family members had repeatedly expressed concerns about the lack of cleaning. Staff interviews confirmed that the cleaning schedule was not being followed, and documentation showed the wheelchair had not been cleaned that week. In another case, a CNA used an expletive to describe a resident's behavior in a public area near other residents and staff. The resident in question had severe cognitive impairment and exhibited physical behavioral symptoms. The facility's policy required staff to treat residents with respect and dignity, but the CNA's public comment violated this expectation. Both the DON and the Administrator acknowledged that such remarks were inappropriate and not in line with facility standards. A third resident, also with severe cognitive impairment and a history of falls, had signs posted in his room and on his walker instructing him to use the call light and ask for help before getting up. These signs were placed without consulting the resident, who found them insulting and irritating. The resident reported that he had used the call light before his falls but staff did not respond promptly, leading him to attempt to use the bathroom independently. Progress notes did not document any discussion with the resident or his representative regarding the addition of these interventions.
Failure to Complete Required Assessments and Vital Signs Documentation After Resident Readmission
Penalty
Summary
The facility failed to complete required physical assessments and document vital signs for a resident who was readmitted following serious medical conditions, including cholecystitis, sepsis, and septic shock. Upon readmission, the clinical record did not include a physical assessment or vital signs on multiple consecutive days. While some pre- and post-dialysis assessments included partial vital signs, there were several days with missing documentation of both vital signs and physical assessments. Additionally, after the resident experienced bleeding from a leg wound and was sent to the emergency department, there was no documentation of an assessment or vital signs upon the resident's return. Progress notes indicated ongoing issues, such as copious drainage from leg wounds, poor circulation, and difficulty obtaining oxygen saturation readings, yet there was still a lack of documented assessments and vital signs. Interviews with the DON and ADON confirmed the absence of required documentation and assessments in the electronic health record. The facility's policy required staff to perform and document a full assessment and vital signs every shift, with no exceptions, especially when a change in condition was observed. Despite this, the required assessments and documentation were not completed for the resident.
Failure to Ensure Safe Wheelchair Transport and Equipment Maintenance
Penalty
Summary
The facility failed to ensure the use of foot pedals during wheelchair transport and did not maintain mobility equipment in good working order, resulting in deficiencies for three residents. One resident with moderately impaired cognition and dependent on staff for wheelchair propulsion was observed being pushed in her wheelchair without foot pedals, causing her feet to lightly touch the ground. Another resident, who had functional limitations in both lower extremities and was at risk for falls, was also transported in a wheelchair without foot pedals. The resident reported that the pedals were often left in his room because they got in the way at the dining table, and there was no bag on the wheelchair to store them. Staff interviews confirmed that missing foot pedals was a recurring issue, and there was no facility policy regarding their use. A third resident, with a history of falls and recent fractures, experienced a fall when his walker collapsed during a transfer from chair to bed. Documentation revealed that the walker was in poor condition with missing screws, and staff confirmed that the equipment was not safe for use. The resident had been permitted by therapy to transfer independently, and the incident was reported to the ADON. The facility's process for monitoring and maintaining equipment safety was not effectively implemented, as evidenced by the use of a defective walker.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by observations and interviews conducted during the survey. On Hall A, 5 out of 9 resident rooms had window curtains that were falling down and not attached to the curtain rods. Similarly, on Hall C, 3 out of 7 rooms had the same issue, while Hall D had 6 out of 11 rooms with curtains falling down, and 2 rooms without any curtains or rods, using a white sheet as a makeshift covering. Room D-12 lacked any window covering entirely. Additionally, the exterior windows in multiple halls were found to be dirty, with dust and grime covering them, affecting 9 out of 9 rooms on Hall A, 4 out of 7 on Hall C, 10 out of 11 on Hall D, and 17 out of 21 on Hall CR. Interviews with residents and staff highlighted the impact of these deficiencies. A resident expressed dissatisfaction with the dirty windows, preferring to keep the curtains closed to avoid looking at them. The Housekeeping Supervisor acknowledged the issues, citing a shortage of housekeeping staff and noting that the exterior windows were last cleaned in the fall, despite a policy directing daily cleaning of windows. The supervisor also mentioned that the problem with curtains falling off rods had persisted for some time, and efforts were underway to install curtain rods in Hall D to address the issue.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as evidenced by an incident involving physical abuse. The resident, who has a history of traumatic brain injury and non-Alzheimer's dementia, requires extensive assistance for daily activities and has severe cognitive impairment, as indicated by a BIMS score of 5 out of 15. On January 15, 2025, a Certified Nursing Assistant (CNA) struck the resident on the back of the head with enough force to cause the resident's chin to move forward towards his chest. This incident was witnessed by a Certified Medication Aide (CMA), who reported the abuse to the charge nurse immediately after it occurred. The Assistant Director of Nursing confirmed that the incident was reported to her on the same day, and the CNA involved was given an opportunity to explain the situation but chose not to provide any explanation. The facility's policy on resident rights clearly states that residents have the right to be free from abuse and neglect, and any suspected violations must be investigated and reported within five working days. Despite this policy, the incident of abuse was not addressed in a timely manner, leading to a deficiency in the facility's obligation to protect the resident's rights.
Infection Control Deficiencies in Dining and Wound Care
Penalty
Summary
The facility failed to maintain a sanitary environment during dining and wound care, leading to potential transmission of infections. During a dining observation, a CNA assisted multiple residents with their meals without sanitizing hands between interactions. The CNA touched various surfaces, including tables, chairs, and residents' utensils, without performing hand hygiene, despite acknowledging the importance of sanitizing hands after touching dirty surfaces and between assisting residents. In another instance, food trays were transported uncovered through a hallway where residents were COVID-positive. A CNA carried trays without covers, exposing the food to potential contamination. The Certified Dietary Manager confirmed that food should be covered during transport, but acknowledged a shortage of covers due to an increased number of room trays required during a COVID outbreak. Additionally, during wound care for a resident, a nurse failed to perform hand hygiene between glove changes while treating open areas on the resident's legs and toes. The nurse acknowledged the oversight in hand hygiene, which is critical for infection control. The facility's infection control program emphasizes the importance of handwashing before and after resident contact and handling soiled items, but these practices were not consistently followed during the observed care.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure resident dignity for two residents, leading to deficiencies in care. For one resident, who had diagnoses including dementia, anxiety, and depression, the facility did not maintain dignity by allowing the resident to be brought into the main dining room without pants, covered only by a blanket. This incident was reported by the resident's family to the facility's social worker, but the grievance form was misplaced and only found later, indicating a lapse in addressing the issue promptly. Another resident, with moderately impaired cognition and requiring extensive assistance for activities of daily living, experienced a lack of dignity during personal care. During an observation, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) failed to adequately prepare for the resident's care, resulting in the resident being left exposed and uncomfortable. The staff did not cover the resident with a sheet while searching for clean clothing, and the resident was not offered the opportunity to wash or sanitize her hands after scratching her buttocks during the care process. The facility's Director of Nursing (DON) acknowledged that the care provided did not meet expectations, noting that staff should have been better prepared and should have maintained the resident's dignity by covering her and offering hand hygiene. The facility's policy on personal degradation emphasizes the importance of maintaining personal dignity, which was not upheld in these instances.
Resident Excluded from Dietary Decision-Making
Penalty
Summary
The facility failed to include a resident in decision-making regarding their care, specifically concerning dietary choices and the need for a swallowing evaluation. The resident, who has end-stage renal disease, anxiety, and depression, was assessed with no cognitive impairment. Despite expressing dissatisfaction with the ground meat diet and requesting a reevaluation, the resident was not included in care plan meetings or decision-making processes. The facility relied on a Durable Power of Healthcare document, which only grants decision-making power to a family member when the resident is unable to make decisions, to justify excluding the resident from these decisions. Interviews with the resident, staff, and family members revealed that the resident had been consuming foods not allowed without issues and was frustrated with the limited dietary options. The speech therapist noted that the order for ground meat was given at the hospital before admission and had not been reevaluated. The Director of Rehabilitation confirmed that a new order for a speech evaluation was made but was delayed due to insurance and co-pay issues. The facility's administrator acknowledged that decisions were directed to the family, assuming the power of attorney was in effect, without confirming the resident's ability to make decisions.
Failure to Update Care Plan for Antidepressant Monitoring
Penalty
Summary
The facility failed to fully review and revise the comprehensive Care Plan for a resident with severe cognitive impairment and multiple diagnoses, including medically complex conditions, cancer, non-Alzheimer's dementia, anxiety disorder, and depression. The resident was prescribed an antidepressant medication, Remeron, in April 2024, but the Care Plan did not include a focus area, goal, or interventions/tasks related to depression or the antidepressant medication. This oversight was identified during a review of the electronic health record, which revealed that the antidepressant was not included in the treatment administration record (TAR) for monitoring. During an interview, the Assistant Director of Nursing, MDS coordinator, and Director of Nursing acknowledged that the antidepressant had not been added to the TAR for monitoring until August 2024, several months after it was prescribed. The MDS coordinator admitted that the antidepressant should have been included in the Care Plan with a focus area, goal, and interventions/tasks to monitor for adverse signs and symptoms. The facility's Care Plan Team policy requires that Care Plans reflect the resident's medical, nursing, and psychosocial assessment, with measurable outcomes and timetables, which was not adhered to in this case.
Failure to Follow Therapeutic Diet for Resident with ESRD
Penalty
Summary
The facility failed to adhere to the prescribed therapeutic diet for a resident diagnosed with End Stage Renal Disease (ESRD) who was on dialysis. The resident, who had no cognitive impairment, was supposed to receive a special renal diet with double protein servings, including double eggs at breakfast. However, during an observation, the resident reported receiving meals that did not align with the dietary orders, such as being served sauerkraut, which is high in sodium and not suitable for a renal diet. The resident also mentioned that the portion sizes, particularly of eggs, were smaller than required. Interviews with the resident and the dietician confirmed the discrepancies in meal service. The dietician acknowledged that the resident should not have been served sauerkraut and that the alternative menu option for the renal diet, roast beef, was not provided. Additionally, the resident was served sausage gravy, which was not part of the renal diet. The facility's diet policy, which was undated, specified that the renal diet should limit high potassium, sodium, and phosphorus foods, and recommended extra protein for dialysis residents, which was not consistently followed in this case.
Failure to Conduct Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to ensure that pre and post dialysis assessments were completed for a resident with end-stage renal disease (ESRD) who required dialysis services. The resident, who had a perfect score on the Brief Interview for Mental Status (BIMS) indicating no cognitive impairment, was scheduled for hemodialysis three times a week. Despite the care plan indicating the need for immediate intervention should complications arise, the resident could not recall any pattern of assessments related to dialysis appointments. A clinical record review confirmed the absence of these required assessments in the resident's records. The Director of Nursing acknowledged the lack of specific assessments for pre and post dialysis, despite being aware of their necessity.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman regarding the transfer of a resident to the hospital, as required by federal regulation. This deficiency was identified during a clinical record review and staff interview, which revealed that the facility did not document the notification of the LTC Ombudsman when Resident #5 was discharged to the hospital. The resident was hospitalized from May 4, 2024, until reentering the facility on May 7, 2024. During an interview, the Administrator confirmed that the LTC Ombudsman was not notified of the transfer and acknowledged the expectation to notify the Ombudsman in such cases. However, the facility lacked a specific policy for notifying the Ombudsman, relying instead on following regulations.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident and their representative of the bed hold policy, including reserve bed payment, during two separate hospitalizations. The resident was discharged from the facility and hospitalized on two occasions, with anticipated returns, but there was no documentation of notification to the resident or their representative regarding the facility's bed hold policy. The facility's computer software program showed the resident's discharge and reentry dates, but the clinical record lacked evidence of written or verbal notification. During an interview, the Administrator acknowledged that a bed hold was not completed for the resident's hospitalizations and stated that it is expected for a bed hold to be completed and explained to the resident or their representative. The facility's bed hold policy requires informing the resident or legal representative of the policy upon admission and prior to, or as soon as possible, after transfer or temporary discharge.
Failure to Follow Care Plan for Resident Transfers
Penalty
Summary
The facility failed to adhere to a resident's Care Plan for transfers, resulting in an incident where a resident was not provided with the required assistance during a transfer in the shower room. The resident, who had a history of polio, repeated falls, and a vertebral fracture, required a mechanical lift with the assistance of two staff members for transfers. However, during the transfer, only one staff member was present, leading to the resident sliding out of the mechanical lift sling. This incident was not immediately reported or assessed by a nurse, and the resident was moved without a proper assessment. The resident, who had intact cognition, reported increased pain in her back and right foot following the incident. The facility's documentation lacked an incident report, a full resident assessment, and timely notifications to the family and provider. The resident's daughter later requested x-rays, which showed no fractures, but the resident continued to experience pain. Interviews with staff revealed inconsistencies in the reporting of the incident, with one CNA admitting to transferring the resident alone and not notifying a nurse immediately. The facility's investigation highlighted that the CNA involved did not follow the Care Plan, which required two staff members for transfers. The CNA admitted to feeling pressured to move the resident quickly and did not wait for a nurse to assess the resident after the fall. The facility lacked specific policies related to resident transfers and assessments, contributing to the deficiency in care provided to the resident.
Failure to Timely Complete Quarterly Assessment
Penalty
Summary
The facility failed to complete a quarterly assessment in a timely manner for one resident. The Minimum Data Set (MDS) for this resident, who had moderate cognitive impairment and diagnoses including acute respiratory failure with hypoxia, sepsis, and congestive heart failure, was overdue by 9 days. The resident required assistance with mobility and transfers. The electronic health record indicated that the quarterly assessment was due on 7/26/24 and should have been completed by 8/9/24, but it was not completed until 8/18/24. The Director of Nursing was unaware of the late MDS and acknowledged the need to investigate the issue. Additionally, the facility did not have a written policy regarding resident assessments and care planning, as confirmed by an email from the Administrator.
Significant Medication Error Due to Misentry in EHR
Penalty
Summary
The facility failed to prevent a significant medication error involving Resident #2, who received Glimepiride 2 mg for 77 days without a diagnosis of diabetes or a physician's order. The error originated when a nurse on duty mistakenly entered another resident's order into Resident #2's electronic health record (EHR). Over the course of 77 days, 11 nurses and Certified Medication Aides (CMAs), the Director of Nursing (DON), the provider during at least three visits, and the pharmacy consultant during at least three Drug Regimen Reviews failed to identify the error. This oversight resulted in Immediate Jeopardy to the resident's health and safety. Resident #2, who had a BIMS score indicating moderate cognitive impairment, was hospitalized with low blood sugar due to the medication error. The resident, who did not have a diagnosis of diabetes, expressed fear and mistrust towards the facility staff, stating that she was not informed about the medication and would have objected if she had been. The resident was found on the floor exhibiting seizure-like activity and was later diagnosed with hypoglycemia at the hospital, where it was confirmed that Glimepiride should not have been prescribed. Interviews with staff revealed a lack of awareness and procedures for double-checking medication orders against diagnoses. Staff members, including CMAs and nurses, did not routinely verify medications against resident diagnoses, and there was no formal policy for medication errors, only an unwritten procedure. The DON confirmed that most medications were administered by CMAs, and the responsibility for comparing orders to diagnoses was shared among the DON, nurses, pharmacy consultants, and providers.
Removal Plan
- Put a new process in place for new orders to be double checked by a 2nd nurse.
- Ensure newly prescribed medications are reviewed by the pharmacy consultant for appropriateness for that resident.
- Contact providers to discuss emphasis of thorough review of Physician Order Sheets.
- Implement medication order audits.
- Audit new processes to ensure expectations are followed.
- Add medication reconciliation to QAPI agenda.
Failure to Provide Consistent Restorative Care
Penalty
Summary
The facility failed to provide consistent restorative care to prevent decline in mobility and range of motion for three residents. Resident #1, who had a history of hemiplegia following a stroke, weakness, and arthritis, required assistance with mobility and transfers. The care plan for Resident #1 lacked documentation of a plan for regular range of motion activities or a walking program. Despite the resident's family expressing concerns about the use of a mechanical lift, there was no documentation of range of motion treatment or services to maintain or improve mobility. Interviews revealed that restorative work was not consistently implemented, and staff were not adequately involved in restorative mobility or range of motion activities. Resident #2, with moderate cognitive impairment and diagnoses including coronary artery disease and congestive heart failure, also lacked a documented plan for regular range of motion activities or a mobility program. The resident was not aware of any restorative or range of motion program and reported not receiving assistance with such activities. Observations confirmed that the resident was not offered these services, indicating a gap in the facility's care planning and execution. Resident #3, who had intact cognition and required assistance with activities of daily living, similarly lacked a documented plan for range of motion activities. The resident reported not being offered range of motion services, despite observing such activities being performed with a roommate. The facility was unable to provide a restorative plan, calendar, training, policy, or procedure for maintaining residents' highest level of functioning, highlighting a systemic issue in the facility's approach to restorative care.
Medication Order Error and Lack of Review
Penalty
Summary
The facility failed to ensure that the resident's doctor reviewed medications and associated diagnoses during required visits, leading to a medication order error for one resident. The resident, who had moderate cognitive impairment and diagnoses of acute respiratory failure, sepsis, and congestive heart failure, was incorrectly administered Glimepiride for diabetes, a condition they did not have. This error went unnoticed during three visits in June 2024, where the provider did not identify the medication order error despite conducting a medication review. The resident received 77 doses of Glimepiride from April to July 2024, which was not ordered in the progress notes. The error was discovered when the resident was admitted to the hospital with hypoglycemia, a condition caused by low blood sugar, which was linked to the unnecessary administration of Glimepiride. The hospital noted that the medication should not have been prescribed as the resident had no history of diabetes. The Director of Nursing confirmed that the facility lacked a written policy for medication errors and had not addressed a new plan for error prevention until after the incident.
Failure to Identify Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure that the pharmacy consultant adequately reviewed the medication regimen for a resident, leading to the administration of an unnecessary drug. The resident, who had moderate cognitive impairment and diagnoses including acute respiratory failure, sepsis, and congestive heart failure, was given 77 doses of Glimepiride, a diabetic medication, despite not having a diagnosis of diabetes. This error was not identified during three separate monthly drug regimen reviews conducted by the pharmacy consultant. The Medication Administration Record (MAR) showed the administration of Glimepiride without corresponding orders in the progress notes. The pharmacy notes from May, June, and July failed to address the Glimepiride, and no pharmacy recommendations were made. The error was discovered only after the resident was hospitalized for hypoglycemia, prompting an investigation by the facility. However, the investigation document did not include interventions involving the pharmacy consultant, and the Director of Nursing confirmed the absence of a written policy or procedure for medication errors.
Failure to Supervise Resident Leading to Fall and Injury
Penalty
Summary
The facility failed to supervise Resident #4 adequately, leading to a fall with injury. Resident #4 had severely impaired cognitive abilities and required extensive assistance for transfers and ambulation. Despite the care plan directing staff to use a walker and provide assistance with all transfers and ambulation, the resident fell while being ambulated by a CNA without a gait belt, resulting in a fracture of the left wrist. The incident occurred in the main dining room, and the resident complained of left wrist pain immediately after the fall. The care plan had been updated to include the use of a gait belt for all transfers and ambulation, but this intervention was not followed at the time of the incident. Staff interviews revealed that the CNA assisting Resident #4 on the day of the fall was new and did not have a cheat sheet or adequate knowledge of the resident's needs. The CNA reported using a walker and holding the resident's hand, but not a gait belt, which was against the facility's policy. The facility's policy required the use of gait belts for all residents needing assistance with transfers and ambulation. The lack of proper supervision and adherence to the care plan and facility policy directly contributed to the resident's fall and subsequent injury. The facility's investigation and staff interviews indicated that there was a communication breakdown and a lack of proper training for new staff. The former DON had implemented corrective actions, including educating staff on the use of gait belts and posting reminders at nurse's stations. However, these measures were not in place or effectively communicated at the time of the incident, leading to the deficiency in care and supervision for Resident #4.
Failure to Provide Required Baths to Residents
Penalty
Summary
The facility failed to provide the required two baths weekly for four out of five residents reviewed. Resident #3, who had severe cognitive impairment and required assistance with transfers, received only two baths during the entire month of December 2023. Resident #4, also with severe cognitive impairment and requiring assistance, received only one bath in February 2024 and four baths in March 2024. Resident #5, diagnosed with diabetes and dementia, received no baths in both February and March 2024. Resident #6, with long and short-term memory impairment, received no baths in March 2024. The facility's records and staff interviews revealed that the issue was partly due to an increase in the facility's census, which led to the addition of a designated bath aide only recently. Prior to this, the aides were responsible for administering showers, often leaving them without breaks. The facility had issued a memo on April 8, 2024, directing nurses and aides to ensure daily shower sheets were filled out and signed, including noting resident refusals. However, this directive was not effectively implemented, leading to the deficiency in providing the required baths to the residents.
Failure to Provide Appropriate Skin Assessments and Interventions
Penalty
Summary
The facility failed to provide appropriate assessments and interventions for residents with impaired skin and changes in condition. Resident #1, who had heart disease, Covid-related weakness, and Alzheimer's, was at risk for skin breakdown due to bladder incontinence. Despite an initial care plan and admission assessment noting skin impairments, no weekly skin assessments were conducted until the week of 4/8/24, leaving the resident without proper monitoring and care for over two months. Resident #8, with cancer, renal insufficiency, and chronic obstructive pulmonary disease, experienced a fall resulting in a closed fracture of the right ulna. Upon return from the hospital, the resident had soiled dressings and extensive edema, but no follow-up orders or assessments were conducted until prompted by the surveyors. The facility staff failed to obtain necessary wound care orders and did not perform timely assessments, leading to inadequate care for the resident's injuries. Resident #6, with dementia and depressive disorder, had a stage III pressure ulcer that was not assessed weekly as required by the facility's policy. Similarly, Resident #9, with congestive heart failure and diabetes, had a stage II pressure injury that was not assessed weekly. Both residents' care plans and physician orders directed specific treatments and assessments, but the facility staff failed to comply with these directives, resulting in insufficient monitoring and treatment of their pressure injuries.
Failure to Follow Care Plan for Resident with Pressure Ulcer Risk
Penalty
Summary
The facility failed to follow the care plan for a resident with impaired cognitive abilities, dementia, and depressive disorder. The resident, who was dependent on staff for transfers and had a history of pressure ulcers, was observed seated in a wheelchair near the nurse's station for an extended period without being repositioned or provided incontinence care. Despite the care plan's directive to assist the resident in shifting weight every 15 minutes and repositioning every two hours, the resident remained in the same position from 8:40 A.M. to 11:12 A.M. without any intervention from the staff. Staff interviews revealed that the resident had been assisted out of bed at 7:00 A.M. and had not received any incontinence care or repositioning since that time. When the resident was finally assisted to bed at 11:20 A.M., a scabbed-over wound on the coccyx was noted, indicating a failure to adhere to the care plan and facility policies for skin care and pressure ulcer prevention. The facility's Skin Care Assessment and Treatment policy mandates regular skin checks, documentation, and repositioning every two hours, which were not followed in this case.
Failure to Follow Physician's Orders for Three Residents
Penalty
Summary
The facility failed to follow physician's orders for three residents, leading to deficiencies in care. Resident #1, who had diagnoses including heart disease, Covid-related weakness, and Alzheimer's, required assistance with transfers, dressing, bathing, and hygiene. Despite a care plan indicating the need for antifungal creams to prevent skin breakdown, staff failed to administer the prescribed medications on multiple occasions, with no documentation of medication refusals. This oversight occurred over a 14-day period before the resident was discharged from the facility. Resident #6, who had impaired cognitive abilities and was dependent on staff for transfers, had a care plan to prevent pressure sores. Despite a physician's order to apply Triad paste three times a day, staff failed to administer the treatment consistently, missing numerous opportunities over several months. This inconsistency contributed to the development and persistence of a stage III pressure ulcer on the resident's coccyx, which showed minimal improvement over time. Resident #9, who had intact cognitive abilities and ambulated with assistance, had a care plan to address a stage II pressure ulcer on his right hip. The physician ordered a specific treatment regimen, but staff failed to administer the Silvadene ointment as prescribed on multiple occasions. The facility's policies on medication administration and skin care were not followed, leading to inadequate treatment and documentation of the resident's condition. The Interim Director of Nurses acknowledged the issue and indicated ongoing efforts to improve staff accountability and documentation.
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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