Oakland Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakland, Iowa.
- Location
- 737 North Highway St., Oakland, Iowa 51560
- CMS Provider Number
- 165230
- Inspections on file
- 34
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 46
Citation history
Health deficiencies cited at Oakland Manor during CMS and state inspections, most recent first.
Multiple residents with chronic pain and serious comorbidities had oxycodone orders and care plans for scheduled and PRN pain control, but an RN tampered with at least seven oxycodone blister cards on two medication carts by puncturing the blisters, removing a total of 279 oxycodone tablets, and resealing the backs with paper tape while replacing the narcotics with loratadine or Vitamin B‑12 tablets. During a routine shift‑change narcotic count, nurses noticed taped blisters and pills that did not match the labeled oxycodone, prompting a facility investigation that linked the discrepancies to one RN who had consistent access to the carts and later admitted to removing and swapping the pills over a period of time. As a result, several residents’ prescribed oxycodone was misappropriated and diverted, despite documentation that their pain regimens were supposed to be maintained and monitored for effectiveness.
The facility failed to report an allegation of suspected narcotic diversion and abuse to the State Agency within the required 2-hour timeframe after it was identified during a shift-change narcotic count. Nursing staff discovered that multiple oxycodone blister cards assigned to several residents with chronic pain and serious comorbidities had been tampered with, with oxycodone tablets removed and replaced by other medications such as loratadine and OTC Vitamin B-12, and blister backs covered with paper tape. Internal documentation shows the DON and Administrator were notified shortly after the discovery, but the Administrator did not successfully complete the electronic report to the State Agency until the following day due to user error. This delay violated the facility’s Abuse, Neglect and Exploitation policy, which requires allegations involving abuse to be reported to the State Agency immediately, but no later than 2 hours after the allegation is made.
A resident with mild cognitive impairment and chronic pain had a PRN oxycodone order for severe pain that was formally discontinued, but the oxycodone card remained in the med cart for months instead of being destroyed or returned per facility policy. Documentation showed the order was discontinued, yet staff did not remove the controlled substance from the cart, and the DON later attributed the oversight to inconsistent staffing. Facility policy required two licensed staff to witness and document destruction or return of unused controlled substances, but this process was not followed, and the narcotic was ultimately misappropriated by a staff member.
A resident with paraplegia, neurogenic bowel and bladder, and a history of a recurrent stage 4 pressure wound was care planned for impaired skin integrity, but weekly skin and non‑pressure wound assessments failed to identify and document an open wound to the gluteal fold that was later described in a progress note as a granulating wound with drainage. The RN responsible for the weekly wound assessment acknowledged performing the assessment on a different day than recorded and focusing only on known areas of concern rather than completing a full head‑to‑toe skin assessment as required by facility policy. In addition, during an observed neurogenic bowel treatment and dressing change to a gluteal wound, two RNs repeatedly changed gloves without performing hand hygiene between glove changes, despite contact with stool and the wound area, contrary to the facility’s hand hygiene policy and the DON’s expectations for hand hygiene during wound care.
Surveyors found that call lights were not answered in a timely manner, with observations of a call light remaining unanswered for over 15 minutes and reports from cognitively intact residents that they frequently waited longer than 15 minutes for assistance. One resident with incontinence reported repeated delays on both shifts, while another resident with renal insufficiency, neurogenic bladder, and paraplegia reported waiting about 20 minutes to be helped to lie down. During a resident council meeting, several residents stated that call lights often took longer than 15 minutes to be answered, especially around shift changes. The DON’s stated expectation and facility policy required timely response and that all staff respond to activated call lights, but these were not consistently followed.
Two residents experienced failures in dignity and respectful treatment during care. One cognitively intact resident with quadriplegia and generalized muscle weakness was left in bed wearing only a brief, without sheets or clothing, while staff left the room to attend to other tasks; the resident reported feeling uncomfortable and that his dignity was not respected until staff later returned to cover him. Another resident with moderate cognitive impairment, hemiplegia, diabetes, and depression, who was totally dependent for personal care, reported that a CNA yelled at her, put her feet back in bed when she was attempting to get out, and tapped or slapped her upper leg, leading the resident to tell the CNA to leave the room; the CNA later denied striking the resident but acknowledged intervening to return her to bed.
Staff failed to promptly separate two residents during a physical and verbal altercation involving a cognitively impaired resident and another resident with behavioral health diagnoses. The incident occurred in the dining area over a dispute about silverware, resulting in one resident being struck in the chest. Staff interviews revealed that immediate separation did not occur, despite facility policy and care plans directing such action to prevent resident-to-resident abuse.
The facility did not complete a thorough investigation after two separate altercations involving a resident with severe cognitive impairment and two other residents. In both incidents, staff intervened and no injuries were reported, but the facility's investigative files lacked staff and resident interviews or statements. The administrator acknowledged that only charge nurse statements were obtained and admitted this was a failure in the investigative process.
A resident with severe cognitive impairment and a history of delusions was placed on one-to-one supervision after an altercation with another resident. Despite this intervention, staff failed to maintain the required supervision, resulting in a second altercation in the dining room. Staff interviews revealed confusion about supervision responsibilities and a lack of clear documentation or protocols for one-to-one supervision.
Two residents with cognitive and psychiatric diagnoses were involved in a physical altercation, resulting in one striking the other. Although staff intervened and attempted to notify management promptly, the incident was not reported to the State Agency within the required timeframe due to communication failures and the absence of the DON, leading to a delay in reporting the abuse allegation.
Two residents with mild cognitive impairment and complex medical histories were involved in a physical altercation, but their care plans were not updated to reflect the incident or to include new interventions, despite facility policy requiring timely care plan revisions by the interdisciplinary team.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
Feeding tubes were utilized for a resident without documented medical necessity or resident agreement, and appropriate care for a resident with a feeding tube was not provided.
Surveyors found that several residents with cognitive deficits were moved between rooms multiple times without documentation of notification or explanation to their representatives, despite facility policy requiring such communication. Interviews and record reviews confirmed that families were not informed, and staff were unaware of the notification policy.
The facility did not consistently notify physicians and resident representatives of significant changes in condition or treatment, including feeding refusals, weight loss, medication changes, high blood sugar, positive Covid-19 tests, and falls with injury. In several cases, families and physicians were not informed in a timely manner, and required documentation of notifications was missing.
The facility did not complete the required additional research for a CNA whose background check was flagged, and the necessary DHS documentation was missing from the employee file, contrary to facility policy.
The facility experienced repeated deficiencies in areas such as infection control, quality of care, notification of changes, and care plan management due to the failure to implement an effective QAPI program. Despite having a QAPI plan and procedures, the facility did not prevent recurring issues, as evidenced by multiple citations over several surveys.
Staff were found to have not fully adhered to facility policies designed to protect a resident from abuse, including the inappropriate use of photographs or recordings. Despite clear policies and signed acknowledgments regarding resident rights and the prohibition of demeaning or unauthorized media use, there was a deficiency in ensuring these protections were consistently upheld.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not properly review and revise care plans for two residents. One resident's care plan did not reflect current feeding tube use and oral intake status, while another resident's care plan lacked goals and interventions related to an ongoing sexual relationship. Staff and policy reviews confirmed that care plans were not updated to match residents' current needs and conditions.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
A resident with paraplegia and total dependence on staff for ADLs did not receive showers as preferred, receiving only bed baths due to staff unfamiliarity with appropriate equipment and inconsistent documentation. The resident expressed a desire for regular showers, but was not consistently offered them, and staff only began using a shower bed after a prolonged period.
A resident with severe cognitive impairment and multiple medical conditions fell while attempting to transfer to the commode after being left alone, despite care plan interventions to prevent such incidents. Following the fall, staff did not complete or document several required neurological assessments at the specified intervals, as confirmed by the DON and clinical record review.
A resident with a suprapubic catheter and multiple health conditions did not have urine output consistently monitored or documented as ordered by a physician. Despite staff being directed to record catheter output each shift and monitor for infection, records showed multiple days with missing documentation. Staff interviews revealed inconsistent practices regarding catheter output monitoring, resulting in a failure to follow care protocols for a resident at risk for urinary tract infection.
A resident did not receive sufficient food and fluids to maintain their health, as required. The facility failed to ensure the necessary provision of nutrition and hydration.
Surveyors observed that staff failed to follow infection control protocols, including proper hand hygiene, glove changes, and use of gowns during high-contact care for three residents with indwelling devices and wounds. Catheter bags were improperly placed, and Enhanced Barrier Precautions were not consistently implemented as required by facility policy and posted signage. Facility leadership confirmed these practices did not meet established infection prevention standards.
During a COVID-19 outbreak, the facility failed to enforce proper infection control measures. Staff and residents were observed not wearing masks, despite signs indicating mask requirements. PPE was available for COVID-19 positive rooms, but adherence to mask-wearing was inconsistent. Staff interviews revealed a shortage of N95 masks and a lack of signage indicating outbreak status. The outbreak involved 22 residents and 9 staff, traced back to a staff member, with one hospitalization reported.
The facility inaccurately submitted staffing reports for the CMS PBJ Staffing Data Report, showing excessively low weekend staffing and resulting in a one-star rating. The facility maintained equal staffing levels during the week and weekends, contrary to the reported data. The Administrator acknowledged the inaccuracy and stated that staffing followed the per patient day (PPD) formula.
The facility did not maintain a sanitary and comfortable environment, as evidenced by unrepaired floor tiles in the north hall. The Maintenance Director, responsible for minor repairs, could not explain the delay in addressing the issue, despite monthly maintenance rounds and a system for logging repairs. The Corporate Director of Operations noted the lack of a specific policy for maintenance repairs.
The facility did not maintain food at a safe temperature during meal service. A cook recorded the breakfast sausage gravy at 180°F initially, but it dropped to 130°F an hour later. The Dietary Manager stated that staff should check temperatures throughout meal service, but the Corporate Director of Operations admitted there was no specific policy for holding temperatures.
The facility failed to properly label stored food, maintain sanitary practices, and ensure effective sanitizer concentration. An RN used a hand hygiene sink for resident water, and several food items were found unlabeled. The sanitizer solution was below the recommended concentration, violating facility policies.
The facility failed to implement proper infection control practices during resident care, medication administration, and laundry delivery. A resident with multiple medical conditions did not have appropriate signage for enhanced barrier precautions, and staff did not consistently perform hand hygiene during wound care. Additionally, staff mishandled medications without proper hand hygiene, and laundry was transported uncovered, contrary to facility policies.
The facility failed to provide residents with access to their personal funds, as residents could only obtain money during limited business office hours. Interviews with residents and staff revealed that funds were inaccessible at night or when specific staff were not present. Grievances were filed due to this issue, and the facility's current practice did not align with its policy, which stated that residents should have access to their funds at any time.
The facility inaccurately assessed and documented the medical status of three residents in their MDS. One resident was incorrectly documented as using anticoagulant therapy instead of anti-platelet medication, another was wrongly recorded as receiving insulin therapy instead of Trulicity, and a third resident's catheter type was misrepresented. The errors were acknowledged by the ADON and DON.
The facility failed to provide comprehensive care plans for two residents, one on anti-platelet therapy and another with multiple diagnoses requiring enhanced barrier precautions (EBP). The care plans lacked necessary focus, goals, and interventions, as acknowledged by the DON.
Two residents were observed being pushed in wheelchairs without foot pedals, contrary to facility expectations and care plans. One resident, with normal cognitive function, required substantial assistance and was pushed by a CNA who had not received training on wheelchair use. Another resident, with severe cognitive impairment, was pushed by an LPN and observed self-propelling without foot pedals. The facility lacked a specific policy on foot pedal use, relying on Standards of Practice.
The facility failed to provide accurate and timely assessments and interventions for several residents. One resident was discharged with medications, including narcotics, without proper authorization. Another resident experienced a fall without receiving a complete assessment. Additionally, two residents had high and low blood glucose levels without proper physician notification.
The facility failed to ensure adequate discharge planning for four residents, leading to delays in receiving medications, lack of home health services, and emergency medical interventions. The residents were discharged without proper coordination of medications, follow-up appointments, or home health services, causing significant issues for the residents and their families.
The facility failed to notify resident representatives after falls for two residents. One resident with moderate cognitive deficits fell while pushing another resident in a wheelchair, and the family was not informed. Another resident with intact cognitive ability reported a fall after getting dizzy, but the emergency contact was not notified. The facility's policy required notifying the physician and resident representative of any change in condition, including accidents or incidents.
The facility failed to follow standard infection control practices during incontinence care for a resident. Two CNAs did not change their gloves or perform hand hygiene after cleaning the resident's legs and buttocks, continuing to use the same gloves while putting on a clean brief and handling a mechanical lift. The resident required substantial assistance and had multiple diagnoses, including anemia and coronary artery disease.
Misappropriation and Diversion of Resident Oxycodone Medications
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their medications, specifically controlled substances (oxycodone) prescribed for pain management. Five residents with chronic pain and multiple comorbidities had oxycodone orders and care plans directing staff to administer scheduled and PRN pain medications and to monitor effectiveness. Documentation showed that these residents generally reported their pain as controlled or at baseline, and observations on various dates confirmed that they denied uncontrolled or increased pain and voiced no concerns. However, during a routine shift-change narcotic count, nursing staff discovered that multiple oxycodone blister cards on two medication carts had been tampered with and that the oxycodone tablets had been removed and replaced with other medications, including loratadine and Vitamin B‑12. For one resident with mild cognitive impairment and chronic pain related to spinal fusion and spondylosis, an oxycodone 5 mg PRN order had been in place, but later review of the narcotic count sheet and medication card showed that there was no oxycodone card present in the cart. Another cognitively intact resident with COPD, heart failure, renal failure, and chronic pain had two oxycodone 5 mg cards that appeared intact and untampered when observed, but the facility’s diversion matrix later identified that 70 oxycodone 5 mg tablets from two cards assigned to this resident had been missing or replaced. A third resident on hospice with chronic pain and multiple serious diagnoses, including emphysema, heart failure, renal failure, dementia, and schizophrenia, had an oxycodone 5 mg PRN order; one packet of oxycodone 5 mg tablets was present and appeared untampered when observed, yet the diversion matrix documented that 11 tablets from one card had been missing or replaced. Another cognitively intact resident with chronic pain from nerve damage after a stroke, who received both scheduled and PRN oxycodone 5 mg, had three packets of oxycodone 5 mg tablets present in the cart that did not appear tampered with at the time of observation, but the facility’s internal review identified that 55 tablets from one card had been missing or replaced. A fifth resident with paraplegia, chronic pain syndrome, and multiple psychiatric diagnoses had an oxycodone 10 mg PRN order; two packets of oxycodone 10 mg tablets were present in the cart and appeared intact, with pink, scored tablets. However, earlier that same day, the DON and staff had identified that this resident’s oxycodone 10 mg card had been tampered with and that all oxycodone tablets in that card had been replaced with OTC pink Vitamin B‑12 tablets, with each blister cavity resealed using small pieces of paper tape. Overall, the facility’s investigation and medication diversion matrix documented that seven oxycodone blister cards assigned to these five residents had been altered, with a total of 279 oxycodone tablets missing and replaced with non‑narcotic medications, constituting misappropriation of resident medications. The facility’s internal investigation, based on pharmacy delivery records, MARs, narcotic control sheets, staffing schedules, and the physical condition of the blister cards, determined that the tampering involved puncturing the blisters, removing oxycodone tablets, and resealing the backs of the cards with paper tape so that the cards appeared intact during routine counts. The investigation concluded that one RN, who had begun working independently on the medication cart where several of the affected residents’ medications were stored, had consistent access to the narcotic supplies during the period when the discrepancies occurred. Law enforcement interviews documented that this nurse ultimately admitted to removing oxycodone tablets from the residents’ blister cards over a period of time, swapping them with loratadine and other OTC tablets, and taking more than one hundred oxycodone tablets, which she stated were later disposed of. These actions resulted in the wrongful use and diversion of residents’ prescribed oxycodone, in violation of the requirement to protect residents from misappropriation of their belongings or money, including medications.
Failure to Timely Report Suspected Narcotic Diversion and Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse, specifically suspected narcotic diversion and medication tampering, to the State Agency within 2 hours as required by facility policy. During a shift-change narcotic count on the 300 medication cart, an agency RN questioned the appearance of one resident’s oxycodone 5 mg blister card, noting that cavity #59 was secured with regular medical tape and that the back of the blister pack appeared tampered with. Further inspection showed that while tablet #59 appeared consistent with oxycodone 5 mg, the remaining tablets in the card had different physical characteristics, and each blister cavity on the back had been covered with small pieces of paper tape. Upon removal and inspection, staff determined that all tablets except #59 had been replaced with a different medication that appeared consistent with loratadine. Following this discovery, nursing staff conducted a review and recount of all narcotic cards on the medication cart and identified additional oxycodone 5 mg and 10 mg blister cards that appeared to have been tampered with in a similar manner. A total of seven blister cards were ultimately identified as affected, with 279 narcotic tablets missing and replaced with other medications, including loratadine and over-the-counter pink Vitamin B-12 tablets. The affected residents had documented chronic pain and opioid orders: one resident with Parkinson’s disease, spinal fusion, and spondylosis had an oxycodone 5 mg PRN order; another resident with COPD, heart failure, renal failure, low back pain, and chronic pain had oxycodone 5 mg PRN for breakthrough pain; a hospice resident with emphysema, heart failure, renal failure, dementia, schizophrenia, PTSD, and spondylosis had oxycodone 5 mg PRN; another resident with stroke, emphysema, a left heel pressure ulcer, and pain had both scheduled and PRN oxycodone 5 mg; and a resident with paraplegia, renal failure, neurogenic bladder, anxiety, depression, bipolar disorder, and chronic pain syndrome had oxycodone 10 mg PRN for severe pain. At the time of surveyor observation in April, the affected residents generally reported their pain as controlled and denied unmanaged pain in the preceding months, and the blister cards then present in the cart did not appear tampered with. The facility’s internal documentation shows that the suspected diversion and tampering were reported to the DON by a staff RN at 6:21 a.m. on March 4, 2026, and the DON contacted the Administrator at 6:27 a.m. that same morning. However, the allegation was not successfully reported to the State Agency within 2 hours. A State Agency complaint intake print screen shows the reporting party as the Administrator, with awareness of the missing medication incident at 6:10 a.m. on March 4, 2026, and a submission date of 11:21 a.m. on March 5, 2026. The Administrator stated he attempted to report the incident on March 4 but did not complete the submission correctly due to user error and did not realize it had not been saved until he returned the next morning and resubmitted it. The facility’s Abuse, Neglect and Exploitation policy requires that all alleged violations involving abuse or resulting in serious bodily injury be reported to the Administrator, State Agency, Adult Protective Services, and other required agencies immediately, but not later than 2 hours after the allegation is made. The surveyors determined that the facility failed to meet this requirement when it did not report the suspected abuse (medication diversion and misappropriation) to the State Agency within the required 2-hour timeframe. The survey findings further detail the scope of the tampering identified in the facility’s medication diversion matrix. One resident’s oxycodone 5 mg card had 59 tablets missing or replaced; another resident had two oxycodone 5 mg cards with a total of 70 tablets missing or replaced; a hospice resident had one oxycodone 5 mg card with 11 tablets missing or replaced; another resident had one oxycodone 5 mg card with 55 tablets missing or replaced; and a resident with chronic pain syndrome had two oxycodone 10 mg cards with 84 tablets missing or replaced. The physical description of the tampering was consistent across cards, with paper tape precisely placed over each blister bubble and the original narcotic tablets replaced by non-narcotic medications. Despite the facility’s internal recognition of this as medication diversion and suspected abuse on the morning it was discovered, the external reporting to the State Agency was not completed within the 2-hour window specified by the facility’s own abuse, neglect, and exploitation policy, leading to the cited deficiency. Resident assessments and care plans documented that these residents were on scheduled and/or PRN opioid regimens for chronic pain and other serious conditions, and the MDS assessments showed varying levels of cognitive function, from no impairment to mild impairment. During the surveyor interviews in April, the residents involved generally denied uncontrolled or increased pain in the prior months and reported that their pain was well managed. Nonetheless, the deficiency centers on the facility’s failure to adhere to its mandated reporting procedures for alleged abuse, specifically the delayed reporting of suspected narcotic diversion and misappropriation of resident medications to the State Agency within the required 2-hour timeframe after the allegation was made.
Failure to Remove and Account for Discontinued Narcotic Leading to Misappropriation
Penalty
Summary
The facility failed to properly remove and secure a discontinued Schedule II narcotic, resulting in misappropriation of the medication by a staff member. A resident with mild cognitive impairment, as indicated by a BIMS score of 8 on a quarterly MDS, had an order for oxycodone 5 mg by mouth every six hours PRN for severe pain related to a left femur fracture. The order, which began in July 2024, was documented as discontinued on a renew orders form dated 10/24/2025, and the October 2025 MAR reflected the discontinuation date. Despite this, the oxycodone medication card remained in the medication cart for almost six months after discontinuation instead of being destroyed or returned to the pharmacy. The resident’s care plan, revised in December 2025, documented chronic pain and increased risk for injury related to spinal fusion and spondylosis, with directions for staff to administer scheduled and PRN pain medications and evaluate their effectiveness. However, once the oxycodone was discontinued, staff did not follow facility policy and accepted professional principles for controlled substance accountability. The DON stated that the discontinued oxycodone card was likely missed due to inconsistent staffing and confirmed that the medication should have been either destroyed by two licensed nurses or, if unopened, returned to the pharmacy. Facility policy required that controlled substances no longer needed be returned to the pharmacy or destroyed, with two licensed staff witnessing and documenting the process, but this did not occur, allowing the narcotic to remain accessible in the cart and be misappropriated by a staff member.
Failure to Accurately Document Skin Assessments and Perform Hand Hygiene During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and document a resident’s skin condition and to perform proper hand hygiene during pressure ulcer care. A cognitively intact resident with paraplegia, neurogenic bowel and bladder, renal failure, chronic pain, and a history of a recurrent stage 4 pressure wound to the left gluteal crease was care planned as being at risk for pressure ulcers and requiring regular skin monitoring and treatments. The quarterly MDS documented that the resident did not have a pressure ulcer, and a weekly nursing skin assessment recorded no alterations in skin integrity, despite a note that a small blister had been charted the previous day. A weekly non‑pressure wound assessment completed by the former ADON/wound nurse documented only a ruptured blister on the inner upper right hip and did not list any additional wounds. Progress notes later documented that, during a neurogenic bowel treatment, nursing staff observed an open skin impairment to the right gluteal fold with granulation tissue, defined borders, peeling/excoriated periwound skin, and serosanguineous drainage with purulent drainage, measuring 4.5 cm x 5.0 cm x 0.2 cm. The nurse cleansed and dressed this wound, indicating that a significant wound was present but had not been captured on the weekly skin or wound assessments. Staff interviews revealed that the nurse who completed the weekly non‑pressure wound assessment had actually performed the assessment on a different day than documented, focused only on known areas of concern, and did not perform a full head‑to‑toe assessment, contrary to facility policy requiring a full body skin assessment and documentation of all wounds and their characteristics. The facility also failed to ensure proper hand hygiene during a pressure ulcer treatment to the resident’s left gluteal fold. During observation of a neurogenic bowel treatment and dressing change, two RNs initially washed their hands, but one RN then touched her hair, picked up wipes from the floor, and moved a trash can before proceeding with care. Throughout the procedure, both RNs repeatedly doffed and donned gloves between steps such as removing the old dressing, cleansing the wound, and applying the new dressing, without performing hand hygiene between glove changes, despite handling stool and the wound area. The facility’s hand hygiene policy required staff to perform hand hygiene using proper technique consistent with accepted standards of practice, and the DON stated that hand hygiene should be performed between glove changes during wound treatments, but this was not followed during the observed care.
Delayed Call Light Response and Inadequate Nursing Staff Responsiveness
Penalty
Summary
Surveyors identified a deficiency related to inadequate nursing staff response to resident call lights, resulting in delays beyond the facility’s own expectation of a 15-minute response time. One resident with a BIMS score of 15 and documented as always incontinent of urine and bowels reported that it frequently took longer than 15 minutes for staff to answer call lights, occurring on both shifts. Continuous observation by surveyors showed a call light in the East hallway remained unanswered for 16 minutes. Another resident, also cognitively intact with a BIMS score of 15 and diagnoses including renal insufficiency, neurogenic bladder, and paraplegia, reported having his call light on while waiting to lie down and stated he had been waiting about 20 minutes, noting that such delays occurred from time to time. During a resident council meeting with multiple residents, participants reported that call lights could take longer than 15 minutes to be answered, particularly at most shift changes. The DON stated her expectation was that call lights be answered within 15 minutes or less. Review of the facility’s policy on call lights indicated that all staff members who see or hear an activated call light are responsible for responding. Despite this policy and stated expectations, surveyor observations, resident interviews, and documentation review showed that call lights were not consistently answered in a timely manner, contributing to the identified deficiency in providing adequate nursing staff response to meet residents’ needs.
Failure to Maintain Resident Dignity and Respect During Care Interactions
Penalty
Summary
Surveyors identified a failure to maintain resident dignity for a cognitively intact resident with quadriplegia and generalized muscle weakness who required assistance with personal care. The resident’s MDS documented a BIMS score of 15, indicating no cognitive impairment. On the observed date and time, a CNA (Staff C) left this resident in bed wearing only a brief, with no sheets or clothing. Staff C left the room and went down the hall to another room, then continued other tasks. During this period, the Activities Director entered the room to deliver mail while the resident remained uncovered. The resident subsequently activated the call light, reporting that staff had left to get linen and that he felt uncomfortable and that his dignity was not respected while lying in bed without a sheet. Staff did not return to cover him until several minutes later, at which time the resident was observed with a blanket on. The resident stated that it usually did not take that long for staff to return to cover him, which was why he used the call light. In a later interview, Staff C acknowledged working that morning, giving showers, and forgetting to put sheets on the resident’s bed. She stated she believed she was not supposed to have a bottom sheet on the air mattress and reported that when she returned to answer the call light, the resident asked to have the blanket put over him. Staff C stated she apologized to the resident and said she had gotten sidetracked. The facility’s dignity policy in effect at the time stated that it was the practice of the facility to protect and promote resident rights, treat each resident with respect and dignity, and maintain or enhance quality of life by recognizing individuality and maintaining privacy. Surveyors also identified a dignity-related concern involving another resident with moderate cognitive impairment (BIMS score of 08) and diagnoses including hemiplegia, diabetes, and depression, who was totally dependent on staff for personal hygiene and dressing. This resident reported that a CNA (Staff P) recently slapped her upper leg while putting her feet back up in bed after noticing her attempting to get out of bed. The resident stated that the CNA was very mean verbally, yelled at her, lifted her feet, put them back in bed, tapped her upper leg, and that she then told the CNA to get out of her room. In a subsequent interview, Staff P stated she assisted the resident back into bed when she saw her trying to get out, was focused on safety because the resident could not walk on her own, and denied touching the resident’s upper leg in the manner described. The facility’s Abuse Prevention policy defined mistreatment as inappropriate treatment or exploitation of a resident and stated that the facility is committed to protecting residents from abuse by anyone.
Failure to Separate Residents During Altercation
Penalty
Summary
The facility failed to separate two residents during a resident-to-resident altercation, resulting in one resident physically striking another. One of the residents involved had severe cognitive impairment, as indicated by a BIMS score of 3, and a history of delusions and impaired short-term memory. The care plan for this resident directed staff to reorient and redirect her as needed. The other resident had no cognitive impairment but had a history of anxiety, depression, and behavioral symptoms. Both residents had documented behavioral care plans that included redirection and education as interventions. On the day of the incident, dietary staff observed the cognitively impaired resident becoming verbally aggressive toward another resident over silverware. The resident then struck the other resident in the chest. Staff interviews revealed that the dietary manager did not immediately separate the residents, citing concerns about holding a coffee pot and the potential for aggression. The nurse was called to the scene, and only then were the residents separated. The resident who was struck denied injury and reported this was the first such incident. Further interviews with staff indicated that the standard response to such altercations would be to redirect and separate the residents, but this was not done promptly in this case. The facility's abuse prevention policy, provided during the investigation, commits to protecting residents from abuse, including from other residents. However, the failure to immediately separate the residents during the altercation constituted a lapse in following this policy and the residents' care plans.
Failure to Conduct Thorough Investigation After Resident Altercations
Penalty
Summary
The facility failed to conduct a thorough investigation following two separate resident-to-resident altercations involving a resident with severe cognitive impairment and two other residents with no cognitive impairment. The first incident occurred when a resident with a BIMS score of 3, indicating severe cognitive impairment, grabbed another resident's wheelchair and began pushing it, then slapped the resident several times on the shoulder after he attempted to remove her hand. The second incident involved the same cognitively impaired resident, who was reported to have hit another resident in the chest during a dispute over silverware. In both cases, staff intervened promptly to separate the residents, and no injuries were reported by the residents involved. Upon review, the facility's investigative files for both incidents were found to be incomplete. The documentation provided included summaries of the investigations, face sheets, care plans, medication changes, and progress notes, but lacked staff interviews or statements and resident interviews or statements. The administrator acknowledged that only statements from the charge nurses on duty were obtained and that no additional interviews with other staff or residents were conducted. The administrator also stated that the resident with severe cognitive impairment was not interviewed due to her condition, and that she did not perceive the resident as violent or capable of causing bodily injury. The deficiency was identified based on the facility's failure to follow a comprehensive investigative process after the altercations. The lack of thorough documentation, including the absence of interviews with all involved parties, contributed to the finding that the facility did not respond appropriately to the alleged violations. The administrator admitted this was a failure in the investigative process, as the standard procedure would typically involve gathering information from all relevant staff and residents.
Failure to Provide Required One-to-One Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide proper supervision for a resident with severe cognitive impairment, resulting in two separate altercations with other residents. The resident in question had a BIMS score of 3, indicating severe cognitive impairment, and diagnoses including hypertensive heart disease, anemia, renal failure, psychotic disorder, mild cognitive impairment, insomnia, and metabolic encephalopathy. The care plan for this resident included interventions for delusions and impaired short-term memory, with specific instructions for staff to reorient and redirect the resident as needed. Following an initial altercation with another resident, the care plan was updated to require one-to-one supervision while the resident was awake due to increased delusions. Despite the updated care plan, staff failed to maintain the required one-to-one supervision. On the day following the first incident, the resident was involved in a second altercation, this time with a different resident in the dining room. Staff interviews and documentation revealed that, although the resident was supposed to be under constant supervision, there was confusion among staff regarding who was responsible for the supervision at the time of the second incident. Staff members were occupied with other duties, such as assisting another resident who had fallen, and were not physically present with the resident as required by the care plan. The lack of clear assignment and documentation for one-to-one supervision contributed to the failure to prevent the second altercation. Further review of facility practices showed that there was no accessible documentation or clear protocol available to staff regarding the implementation of one-to-one supervision. The MDS Coordinator was unable to provide documentation for the supervision during the relevant period, and staff interviews indicated uncertainty about the expectations and procedures for one-to-one supervision. The administrator confirmed that staff were not within the required proximity to the resident during the incident, and there was no indication that alternative supervision measures, such as 15-minute checks, were implemented when one-to-one supervision could not be maintained.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving two residents. One resident, who had a history of dementia, schizophrenia, neurogenic bladder, and PTSD, and was assessed as having mild cognitive impairment, became agitated and physically struck another resident in the face after a verbal altercation. The incident occurred in a common area and was witnessed by nursing staff, who intervened to separate the residents. The facility's policy requires that allegations of abuse be reported immediately, but not later than two hours after the event if it involves abuse or results in serious bodily injury. Despite the policy, the incident was not reported to the State Agency until nearly two days later. The delay occurred because the charge nurse attempted to notify the Administrator shortly after the incident, but the Administrator did not respond until several hours later, citing personal errands. Additionally, the Interim DON had quit via text message on the day of the incident, contributing to the communication breakdown. The Administrator acknowledged that the late reporting was her responsibility and that the charge nurse had attempted to follow proper procedures.
Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to update the care plans for two residents following a resident-to-resident altercation. One resident, with a history of dementia, neurogenic bladder, schizophrenia, and PTSD, became agitated and physically aggressive, ultimately striking another resident in the face. The altercation was documented in progress notes, and both residents were separated by staff before further escalation. Despite this incident, a review of the care plans revealed that neither resident's care plan was updated to reflect the altercation or to include interventions to address the event. Interviews with staff indicated that responsibility for updating care plans lies with the nurse in charge or the individual completing the incident report, but the care plans remained unchanged after the incident. The facility's policy requires a person-centered care plan to be developed and revised by an interdisciplinary team to address residents' needs and incidents, but this was not followed in the case of these two residents. Both residents had mild cognitive impairment and relevant medical conditions at the time of the deficiency.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Ensure Medically Necessary Use and Proper Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the intervention. Additionally, appropriate care and services for a resident with a feeding tube were not provided as required. The report identifies a failure to ensure that feeding tubes are only used when medically necessary and with resident consent, as well as a lack of proper care for residents with feeding tubes.
Failure to Notify Residents or Representatives of Room Changes
Penalty
Summary
The facility failed to notify residents or their representatives of room changes or provide explanations for these changes for four residents with varying degrees of cognitive impairment. Observations, interviews, and record reviews revealed that residents with severe to moderate cognitive deficits were moved between rooms multiple times without documentation of family notification or explanation for the moves. In several cases, residents exhibited behaviors such as wandering, confusion, and verbal altercations, yet there was no evidence that families were informed or involved in care conferences regarding these changes. For example, one resident with a history of wandering and elopement risk was moved four times, and her family reported not being notified or invited to care conferences. Another resident, also with severe cognitive impairment and anxiety, was moved twice in a short period, with nursing notes indicating increased confusion and distress, but no documentation of family notification or rationale for the moves. Additionally, two other residents with moderate cognitive deficits and complex medical histories were moved between rooms without documented explanations or notifications to their families. The facility's policy required social services to complete a room change form and notify residents or their representatives, but staff interviews indicated a lack of awareness of this policy. The administrator acknowledged that the social worker was not aware of the notification policy and stated that she would expect staff to communicate with residents and their representatives prior to room changes. However, the records reviewed did not show that these procedures were followed.
Failure to Notify Physicians and Representatives of Changes in Condition
Penalty
Summary
The facility failed to notify physicians and resident representatives of significant changes in condition or treatment for four residents. For one resident with a history of cancer, dysphagia, and a feeding tube, there were multiple refusals of enteral and oral feedings, as well as a documented weight loss of 5 pounds in one week and a total loss of over 25 pounds since the previous year. Despite care plan interventions requiring physician notification for significant weight loss and feeding refusals, there was no evidence that the physician was informed of these changes. Staff interviews confirmed that such notifications should have occurred, and the physician stated she was only recently made aware of the resident's weight loss and refusals. Another resident with diabetes and psychiatric diagnoses experienced a change in psychotropic medication and a critically high blood sugar reading. The resident's Power of Attorney (POA) was not notified of the medication change until behavioral symptoms emerged, and there was a delay in notifying both the POA and physician about the high blood sugar. Documentation of physician notification and orders for insulin was lacking in the medical record, and staff confirmed that notification should have been made for such changes in condition. Additional deficiencies included failure to notify a resident's family of a positive Covid-19 test result and failure to inform a family member of a fall resulting in injury, despite care plan interventions and facility policy requiring such notifications. In one case, the family only learned of a positive Covid-19 result after calling the facility following an automated message, and in another, the family was not informed of a fall with injury until contacted by hospice. The facility's policy required timely notification of changes in condition, but documentation and interviews revealed that these notifications were not consistently made.
Failure to Complete Required Background Check Research for CNA
Penalty
Summary
The facility failed to complete the required additional research for a Certified Nursing Assistant (CNA) whose background check indicated further investigation was necessary. The CNA was hired and had a background check completed, which documented that additional research was required. However, the employee file did not contain the Department of Human Services (DHS) release indicating whether the CNA was eligible to work in the facility following the additional criminal history research. Interviews with facility staff revealed that the process for handling flagged background checks involved notifying the employee, collecting additional paperwork, and waiting for DHS results before allowing the individual to work. Despite this, the necessary documentation was missing from the CNA's file, and the Administrator was unable to locate the DHS work letter. The facility's policy stated that background checks would be completed and individuals with a history of abuse, neglect, or misappropriation would not be employed, but this procedure was not followed in this instance.
Repeat Deficiencies Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to ensure the implementation of a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies identified during multiple annual, revisit, and complaint surveys over a three-year period. Deficiencies cited included issues with notification of changes, quality of care, tube feeding management, infection control, development and implementation of abuse/neglect policies, accidents and hazards, nutrition/hydration status maintenance, care plan timing and revision, and services provided meeting professional standards. These deficiencies were documented through reviews of the Department of Inspections, Appeals, and Licensing website, which showed repeated citations for the same or similar issues across several surveys. Despite having a QAPI plan and procedures in place, the facility's actions did not prevent the recurrence of these deficiencies. The QAPI documentation described a structured, data-driven approach involving interdisciplinary teams and input from residents and staff, with processes for identifying and addressing quality care and process improvement opportunities. However, the repeated nature of the cited deficiencies indicates that the QAPI program was not effectively implemented or sustained, resulting in ongoing noncompliance with regulatory requirements related to quality assurance and performance improvement.
Failure to Protect Residents from Abuse and Inappropriate Use of Media
Penalty
Summary
Staff D's employee file included a signed document acknowledging the rights of residents to be free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, and unauthorized use of physical or chemical restraints. The facility's policies prohibit staff from taking or distributing photographs or recordings of residents in any manner that could demean or humiliate them, including sharing such content on social media or through multimedia messages. The employee handbook further restricts the use of personal cell phones while on duty and emphasizes the importance of maintaining resident confidentiality and dignity in all communications, including online activity. The facility also maintains a policy requiring a media release form to be signed by residents for any photographic or video recordings, specifying the intended use and allowing residents to revoke authorization at any time. Despite these documented policies and procedures, the report indicates a deficiency related to the protection of residents from all forms of abuse, including the inappropriate use of photographs or recordings, suggesting that the facility's practices or staff actions did not fully align with established protocols to safeguard resident rights and privacy.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Revise and Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise care plans for two residents as required. For one resident with a history of cancer, anxiety, depression, psychotic disorder, spinal stenosis, and dysphagia, the care plan did not accurately reflect the resident's current status regarding the use of a feeding tube at night and supervised oral intake. The care plan contained outdated interventions, such as indicating the resident was independent with eating and NPO, despite changes in the resident's condition and physician orders. Staff interviews confirmed that the care plan should match the resident's current needs and abilities, and the facility's policy required updates to the care plan upon a change in condition. For another resident with moderate cognitive deficits, serious mental illness, and a legal guardian, the care plan failed to include goals and interventions related to the resident's ongoing sexual relationship with another resident. Although the care plan noted the existence of a sexual relationship, it lacked specific interventions or goals to address this issue. The administrator acknowledged that such information should be included in the care plan. These deficiencies were identified through observations, staff interviews, clinical record review, and policy review.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, nor does it mention particular residents or their medical conditions at the time of the deficiency.
Failure to Provide Bathing per Resident Preference and Care Plan
Penalty
Summary
A deficiency occurred when a resident with paraplegia and significant self-care deficits did not receive bathing services according to their preferences and care plan. The resident, who was totally dependent on staff for hygiene and transfers, was only provided bed baths because staff believed he lacked the trunk support necessary to use a shower chair. Staff were unfamiliar with the use of a shower bed, which was only located and utilized after a significant period. Documentation showed that the resident received only one shower over several weeks, with multiple gaps where showers were not offered or documented, and some refusals not followed up with additional offers. The resident expressed a desire for a real shower at least once a week, but staff continued to provide only bed baths until the shower bed was found. The facility's policy required staff to assist with bathing to promote cleanliness and dignity and to notify the charge nurse of refusals, but records indicated inconsistent documentation and lack of regular shower offers. The resident's medical history included neurogenic bladder, paraplegia, recurrent hip dislocation, pressure ulcer, insomnia, and adult failure to thrive, and he was totally dependent on staff for all ADLs.
Failure to Complete Required Neurological Assessments After Resident Fall
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 4, and multiple diagnoses including non-Alzheimer's dementia, hypertensive urgency, pneumonia, adult failure to thrive, and dysphagia, experienced a fall in her bedroom after attempting to transfer from bed to the commode. The care plan for this resident identified her as being at risk for falls and included specific interventions such as not leaving her alone on the toilet/commode, keeping walkways clear, and applying nonskid strips. Despite these interventions, the resident was left alone and subsequently fell while transferring. Following the fall, the facility's protocol required a licensed nurse to perform neurological evaluations at specified intervals over a 72-hour period, with documentation on a Neurological Evaluation Form. However, staff failed to complete and document several required neurological assessments at multiple scheduled times. The Interim DON confirmed that the neurological checks were not performed as required, and the clinical record review showed missing entries for the mandated assessments.
Failure to Monitor and Document Catheter Output for High-Risk Resident
Penalty
Summary
The facility failed to consistently monitor and document urine output for a resident with a suprapubic catheter who was at risk for urinary tract infections. The resident, who had diagnoses including neurogenic bladder, paraplegia, and adult failure to thrive, was totally dependent on staff for care and had a physician order requiring staff to record catheter output per shift and monitor for signs and symptoms of infection. Despite this, review of the Medication and Treatment Administration Records showed that urine output was only documented once on three separate days in June, and there was no documentation of urine output from June 24th to June 30th. Additionally, the Point of Care Response History lacked documentation of urine output for a full week in July. Staff interviews revealed inconsistent practices regarding urine output monitoring, with a nurse consultant stating that output was not monitored on all catheters unless there was a physician order or the resident was considered high risk, despite the presence of such an order for this resident. The resident had previously been admitted to the hospital with septic shock, and facility policy and nursing references indicated the importance of monitoring urine output and promptly reporting abnormal changes. The lack of consistent monitoring and documentation represented a failure to follow physician orders and established care protocols for residents with urinary catheters.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices involving three residents with indwelling medical devices and wounds. For one resident with a suprapubic catheter, the catheter bag was observed lying on the floor while the resident was in bed, which was acknowledged by facility leadership as inappropriate placement. Another resident with a gastrostomy tube and wounds was observed during care where the registered nurse inconsistently performed hand hygiene, failed to use a gown as required by Enhanced Barrier Precautions (EBP), and did not maintain a clean environment when handling supplies and performing dressing changes. The nurse also failed to use a barrier for clean supplies and did not consistently change gloves or perform hand hygiene between clean and dirty tasks. A third resident, who was totally dependent on staff for hygiene and had an indwelling urinary catheter and wounds, received personal incontinence care from two certified nurse aides. During this care, the staff did not wear gowns as required by EBP, and the resident's catheter bag was placed on the bed during the procedure. Facility policy required the use of gown and gloves for high-contact care activities involving indwelling devices and wounds, but these protocols were not followed during the observed care events. Interviews with facility leadership confirmed that the observed practices did not meet the facility's expectations or policy requirements for infection control, hand hygiene, and EBP. The facility's own policies, as well as posted signage, specified the need for gown and glove use during high-contact care for residents with indwelling devices or wounds, and for proper hand hygiene before and after glove use and care activities. These deficiencies were identified through direct observation, record review, and staff interviews.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement appropriate infection control practices during an active COVID-19 outbreak, as observed by surveyors. Upon entry, a sign indicated that all visitors must wear masks due to COVID-19, yet several staff members and residents were observed not adhering to this protocol. Staff A, a Dietary Cook, walked through the facility without a mask, passing by residents who were also not wearing masks. Additionally, Staff F, a Pharmacy Consultant, was seen without a mask in the Supply Room, and Staff G had to educate them on keeping the door closed if not wearing a mask. The facility had 14 rooms designated as COVID-19 positive, with PPE available outside each door. However, only a few residents were observed wearing masks, and only one wore it correctly. Staff interviews revealed that there was a shortage of N95 masks, leading some staff to double up on surgical masks when entering COVID-19 positive rooms. Despite the outbreak status, there was no signage at the entrance indicating the facility's outbreak status or mask recommendations. Staff interviews confirmed that the facility had been in outbreak status since 12/16/24, with 22 residents and 9 staff testing positive for COVID-19. The outbreak was traced back to a staff member, and there had been one hospitalization but no deaths. Staff were aware of the requirement to wear masks and PPE when entering COVID-19 positive rooms, but there was inconsistency in adherence to these protocols. The facility's policies referenced CDC guidelines for infection control, but these were not effectively implemented during the outbreak.
Inaccurate PBJ Staffing Report Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period of April 1 to June 30. The report, run on November 13, 2024, indicated excessively low weekend staffing and resulted in a one-star staffing rating. Upon review, it was found that the facility maintained equal staffing levels during the week and weekends, contrary to what was reported. The Administrator acknowledged the inaccuracy in the PBJ report and stated that the facility followed the per patient day (PPD) formula defined in the facility assessment for staffing numbers, with no changes made for weekend staffing.
Failure to Maintain a Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, as evidenced by observations of missing or damaged floor tiles in the north hall. Despite the facility's census of 51 residents, the necessary repairs were not completed over several days. The Maintenance Director acknowledged responsibility for minor repairs, including floor tile repair, but could not provide a reason for the delay in addressing the issue. Maintenance rounds were reportedly conducted monthly, and cosmetic repairs were logged in a facility application accessible to all staff. However, there were no unresolved building repairs noted in the system. Additionally, the Corporate Director of Operations confirmed the absence of a specific policy for maintaining a homelike environment or addressing maintenance repairs.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at a safe and appetizing temperature during meal service. On the morning of November 20, 2024, a cook checked the temperature of the breakfast sausage gravy, which was initially recorded at 180°F. An hour later, the temperature of the same item had dropped to 130°F. The Dietary Manager indicated that staff are expected to check food temperatures before, during, and after meal service to ensure compliance with regulatory standards. However, the Corporate Director of Operations acknowledged that the facility lacked a specific policy regarding holding temperatures for meal service.
Deficiencies in Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage, labeling, and sanitation practices, as observed during a survey. A Registered Nurse (RN) was seen using a hand hygiene sink to fill a pitcher of water for resident use, which is against the facility's policy. Additionally, the kitchen contained several unlabeled food items, including a package of pink meat and a tan pitcher of liquid in the refrigerator, as well as two clear bags of multicolored items in the pantry. These observations indicate a lack of compliance with the facility's policy that requires all food items to be dated and labeled. Furthermore, the facility did not maintain the appropriate concentration of sanitizer solution for food preparation surfaces. A dietary aide documented a sanitizer concentration of 100 parts-per-million (ppm), which is below the manufacturer's recommended 200 ppm for effective sanitation. The facility's policies, including those on nutritional services sanitation and hand hygiene, were not followed, contributing to the deficiencies observed. The Dietary Manager confirmed that staff should not use the hand hygiene sink for non-hand hygiene purposes and that sanitizer solutions should be prepared fresh before each meal service.
Infection Control Deficiencies in Resident Care and Facility Operations
Penalty
Summary
The facility failed to implement appropriate hand hygiene and infection control practices during resident care, medication administration, and laundry delivery. Resident #48, who had multiple medical conditions including septicemia and a pressure ulcer, did not have signage indicating the need for enhanced barrier precautions (EBP). During wound care, staff members did not consistently perform hand hygiene when changing gloves, which is against the facility's policy and CDC guidelines for infection prevention. In addition to the issues with resident care, there were multiple observations of improper hand hygiene during medication administration by various staff members. Staff members were observed handling medications with bare hands, failing to perform hand hygiene before and after glove use, and improperly managing spilled medications. These actions were contrary to the facility's medication administration policy, which requires hand sanitization between tasks and proper handling of medications. The facility also failed to maintain proper infection control practices during laundry delivery. Staff were observed carrying uncovered laundry close to their faces and allowing it to touch the floor, which is against the facility's policy for handling linen and laundry. The policy requires that clean laundry be covered during transport to prevent contamination. These deficiencies highlight a lack of adherence to established infection control protocols, potentially increasing the risk of pathogen spread within the facility.
Facility Fails to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to provide residents with access to their personal funds managed by the facility, as evidenced by interviews with residents and staff, and a review of facility policies. Resident #4, with no cognitive impairment, reported that he could only obtain money during the business office hours, which were limited to 9 am to 2 pm, Monday through Friday. This restriction meant that residents could not access their funds at night or when the business office was closed. Similarly, Resident #21, also with no cognitive impairment, confirmed that money was kept in a safe by Staff K, and if neither Staff K nor the Administrator was present, residents could not access their funds. Staff interviews further corroborated the issue, with Staff L, an RN, stating that cash was not available in the evenings or on weekends when Staff K was not present. Staff F, an LPN, mentioned discussions about making a lockbox available for weekends and overnights, but this had not been implemented. Staff K, the Business Office Manager, acknowledged that residents did not have access to their funds unless she was working and mentioned a plan to prepare funds in advance for residents. However, grievances had been filed by residents due to the unavailability of funds, and the facility had not yet finalized a policy to address this issue. The facility's policy review revealed that residents should have access to their funds during normal banking hours and be able to make withdrawals at any time. However, the current practice did not align with this policy, as residents were unable to access their funds outside of limited hours when specific staff were present. The Administrator admitted that there was no access to personal funds on weekends or evenings when she or Staff K were not at the facility, and acknowledged grievances related to this issue. The facility was in the process of developing a new policy but had not yet implemented it.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately assess and document the medical status of three residents during the observation period of the Minimum Data Set (MDS). For Resident #25, the MDS inaccurately documented the use of anticoagulant therapy, while the Medication Administration Record (MAR) showed a prescription for clopidogrel bisulfate (Plavix), an anti-platelet, not an anticoagulant. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the error, noting a misunderstanding of the medication classification. Similarly, Resident #32's MDS incorrectly recorded insulin therapy, although the MAR indicated a prescription for Trulicity, a non-insulin medication. The ADON confirmed that Resident #32 had never been on insulin, and the MDS was coded incorrectly. For Resident #48, the MDS inaccurately documented the use of an external catheter, while the care plan and MAR indicated the use of an indwelling catheter due to a diagnosis of neurogenic bladder. The DON and Regional Nurse Consultant confirmed the error, stating that the care plan was correct, but the MDS was not. The facility's policy requires the MDS to be completed using direct observation, communication, and medical record documentation, which was not adhered to in these cases.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to provide a comprehensive care plan for two residents, leading to deficiencies in addressing their specific medical needs. Resident #25, who had no cognitive impairment, was prescribed clopidogrel bisulfate (Plavix), an anti-platelet medication. However, the resident's care plan did not include any focus, goals, or interventions related to the use of this medication, which is essential for managing the risk of bleeding. The Director of Nursing (DON) acknowledged the absence of a care plan addressing the anti-platelet therapy, despite the facility's policy requiring a person-centered care plan for each resident. Resident #48, with moderate cognitive impairment, had multiple diagnoses including septicemia, multiple sclerosis, and a pressure ulcer, among others. The resident's care plan lacked documentation for enhanced barrier precautions (EBP), which are crucial for infection control, especially given the resident's indwelling catheter and pressure ulcers. The DON confirmed that the need for EBP should have been noted in the care plan, indicating a lapse in the facility's adherence to comprehensive care planning for residents with complex medical needs.
Failure to Ensure Safe Wheelchair Use for Residents
Penalty
Summary
The facility failed to protect residents from potential accidents and injuries, as observed in the cases of two residents. Resident #8, who has normal cognitive function and requires substantial assistance, was observed being pushed in a manual wheelchair without foot pedals by a Certified Nursing Assistant (CNA). The CNA, who was a contract staff member, stated that she had not received training from the facility regarding the use of wheelchairs and transfers. This action was contrary to the resident's care plan, which required the use of a Hoyer lift for transfers. Resident #15, who has severe cognitive impairment and can self-propel a wheelchair with setup assistance, was also observed being pushed without foot pedals by a Licensed Practical Nurse (LPN). Additionally, the resident was seen self-propelling the wheelchair within the facility. Staff interviews revealed that the facility's expectation was for foot pedals to be used when pushing residents in wheelchairs, and this had been communicated through training. However, the facility did not have a specific policy regarding the use of foot pedals, relying instead on Standards of Practice.
Failure to Provide Accurate and Timely Assessments and Interventions
Penalty
Summary
The facility failed to provide accurate and timely assessment and interventions for several residents. For Resident #3, the staff did not obtain a physician's order for home medications upon discharge. The LPN was instructed by the Administrator to send leftover medications, including narcotics, with the resident without proper authorization. The Nurse Practitioner confirmed that she would never authorize sending narcotics home without a separate prescription, and the facility policy required a prescriber's order for discharge medications, which was not followed in this case. Resident #4 experienced a fall and reported dizziness and hitting her head. However, the chart lacked a complete assessment, including neurological checks and a full body assessment after the unwitnessed fall. The DON and ADON acknowledged the absence of an incident report and necessary assessments, which were expected per facility policy. The resident later reported that staff did not check her head or body for injuries after the fall. For Residents #2 and #9, the facility failed to notify the physician of high and low blood glucose levels as required. Both residents had multiple instances of blood glucose readings outside the specified parameters, but the nursing notes lacked documentation of physician notification. The DON initially thought the notification threshold was a mis-entry but later confirmed the correct parameters. The NP noted inconsistent communication between the facility and providers, which hindered timely follow-up and appropriate orders.
Inadequate Discharge Planning for Multiple Residents
Penalty
Summary
The facility failed to ensure adequate discharge planning for four out of five residents reviewed. Resident #1 was discharged without proper coordination of home medications, leading to a delay in receiving essential medications. The resident's family was unprepared for the discharge, and the facility did not ensure that the necessary follow-up appointments and home health services were arranged. The resident experienced adverse symptoms due to the lack of timely medication access. Resident #3 was discharged without sufficient insulin and other necessary medications. The facility did not provide the resident with a complete medication list or ensure that the pharmacy had the proper paperwork to dispense the medications. The resident's blood glucose levels became dangerously high, requiring emergency medical intervention. The home health nurse had to arrange for the resident to see a doctor and obtain the needed medications. Resident #6 was discharged without home health services, follow-up appointments, or prescriptions. The resident's daughter was forced to take him home due to financial constraints, and the facility did not complete the necessary discharge paperwork or medication list. Similarly, Resident #4 was discharged without prior notification to the family and without arranging home health services. The resident experienced a fall shortly after discharge and was readmitted to another facility. The facility's failure to coordinate discharge planning and ensure continuity of care led to significant issues for the residents involved.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to notify resident representatives after falls for two residents. Resident #6, who had moderate cognitive deficits and required assistance with daily activities, fell while pushing another resident in a wheelchair. Although the incident report indicated that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) notified the physician, there was no documentation of family notification. A family member confirmed that they were unaware of the fall incident. Resident #4, who had intact cognitive ability and required substantial assistance with mobility and personal hygiene, reported a fall to staff after getting dizzy and hitting her head. The emergency contact for Resident #4 stated that they were not informed about the fall. The DON and ADON assumed the representative was informed during the resident's discharge, but the chart lacked a neurological or full body assessment after the unwitnessed fall. The facility's policy required notifying the physician and resident representative of any change in condition, including accidents or incidents.
Failure to Follow Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to follow standard infection control practices related to proper hand hygiene for one of the three residents reviewed. During incontinence care for a resident, two CNAs did not change their gloves or perform hand hygiene after cleaning the resident's legs and buttocks. The CNAs continued to use the same gloves while putting on a clean brief, pulling up the resident's pants, and handling the mechanical lift. One CNA removed her gloves but did not use sanitizer, while the other CNA did not change her gloves at all. The resident involved had a BIMS score of 14, indicating intact cognitive ability, and required substantial assistance with dressing, hygiene, and was totally dependent on staff for toileting and bathing. The resident had multiple diagnoses, including anemia, coronary artery disease, heart failure, renal insufficiency, diabetes mellitus, and a cerebrovascular accident. At the time of the incident, the resident was on an antibiotic for acute cholecystitis. The facility's hand hygiene policy, last reviewed on 4/28/22, indicated that hand hygiene should be performed following clinical indications, including before and after providing care and contact with blood, body fluids, or contaminated surfaces.
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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