Oelwein Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oelwein, Iowa.
- Location
- 600 Seventh Street Se, Oelwein, Iowa 50662
- CMS Provider Number
- 165341
- Inspections on file
- 16
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Oelwein Health Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia developed an unexplained bruise above the right eye that staff observed and documented, but the provider and family were not notified for 8 days. Multiple staff members saw the bruise over several shifts and described it as worsening, while the resident’s sister later reported the injury to the DON. Interviews confirmed that nurses were expected to document the injury, complete an incident report, and notify the MD and family promptly.
Incomplete hospital transfer documentation was found for two residents whose records lacked copies of transfer paperwork. One resident was cognitively intact, dependent for transfers, and had diagnoses including malnutrition, a pressure ulcer, and paraplegia; the other was cognitively intact with paraplegia, diabetes, and anxiety and was transferred for sepsis and a UTI. The DON stated the nurse failed to copy the paperwork sent with both residents, and staff identified required transfer documents such as the Resident Transfer Sheet/Record, MAR, TAR, immunization records, advance directives, and pertinent lab or x-ray results.
The facility failed to timely transmit a DRNA assessment for a resident who had discharged from the facility. The assessment was completed and later accepted in iQIES, but an LPN said she believed it remained marked not to submit because the resident had Medicare Advantage coverage and that she usually waited for DON sign-off before weekly transmission. The CMS LTC RAI Manual required transmission within 14 days of completion, but the record was sent far later than required.
A resident’s MDS was coded with schizophrenia based on old records rather than current documentation. The resident had intact cognition and current diagnoses of GAD, depression, agoraphobia with panic disorder, PTSD, and major depressive disorder, while the PMHNP stated she had not diagnosed schizophrenia or schizoid personality disorder and did not view those old diagnoses as relevant to the resident’s current condition. The LPN and DON both relied on the historical 1990 diagnosis when entering/coding quetiapine and schizophrenia, even though current provider notes did not support schizophrenia.
The facility failed to document provider notification for repeated critical blood glucose values for two residents with diabetes, including severe hypo- and hyperglycemia. The facility also failed to complete timely neuro assessment after an unexplained bruise was found on a resident’s head/face; staff noted the injury over several days, but the record lacked prompt follow-up documentation. The DON confirmed the chart lacked physician notification for one resident’s abnormal blood sugars, and staff stated a neuro exam would be expected for a new head bruise.
A resident with dysphagia, a mechanically altered diet, and documented coughing during meals was allowed to be fed by PNAs even though the care plan and swallow study identified aspiration concerns and safe-swallow precautions. Staff interviews showed PNAs assisted the resident routinely, one PNA reported coughing after every drink, and the DON stated the facility did not have residents PNAs could not assist, despite policy limiting residents with recurrent aspiration or difficulty swallowing to licensed or certified staff.
Failure to Perform Hand Hygiene and Proper Commode Cleaning: A CNA assisted a resident with a commode and handled a pan with visible BM without consistent hand hygiene. The CNA removed gloves multiple times without washing hands, carried the contaminated pan to the dirty utility room, left visible BM on the rim after rinsing, and completed only a brief hand wash. The resident reported staff often did not wash hands or use sanitizer after emptying the commode bucket, and an LPN and the DON verified the hand hygiene concerns.
A facility failed to complete a Significant Change Status Assessment (SCSA) MDS in a timely manner for a resident who elected hospice services. Despite the resident's admission to hospice care, the facility did not document hospice as the primary payer, and the SCSA MDS was not completed within the required timeframe. Interviews revealed a lack of awareness and communication among staff regarding the completion of the SCSA MDS.
A facility failed to update a resident's Care Plan to include hospice services, despite the resident being on hospice care. The resident had moderate cognitive impairment and other health conditions. The MDS Coordinator acknowledged the oversight, and the DON confirmed the MDS Coordinator's responsibility for Care Plan updates.
Improper food handling practices were observed during the preparation of pureed meals, where a dietary staff member used a single gloved hand to handle buttered bread slices, risking cross-contamination. The Dietary Manager confirmed the staff member should have used tongs and acknowledged the facility lacked a specific food handling policy, relying instead on the Iowa Food Code.
A facility failed to accurately complete the MDS for a resident, incorrectly documenting the use of a feeding tube. Observations and staff interviews confirmed the resident did not have a feeding tube, and the MDS coordinator admitted the error. The facility lacked a specific policy for MDS completion, relying on the RAI 3.0 User's Manual.
The facility inaccurately reported staffing information to CMS for FY Quarter 1, as the PBJ report indicated low weekend staffing despite daily sheets and schedules showing over 2.0 hours per resident per day. Observations confirmed residents were well cared for. The Administrator, DON, and HR stated that the corporate office handles PBJ data submission without a preliminary review.
Delayed Notification of Significant Facial Bruising
Penalty
Summary
The facility failed to notify the provider and family of a significant injury for Resident #17 after staff identified an unexplained bruise to the right eye. Staff first documented the bruise on 3/15/26, describing it as approximately 2 cm by 2 cm above the right eye, but the clinical record did not show notification to the medical provider or family until 3/23/26, creating an 8-day delay. The resident’s record showed severe cognitive loss, Alzheimer’s disease and non-Alzheimer’s dementia, hallucinations, rejection of care, and physical and verbal behaviors toward others, with no documented upper or lower extremity range-of-motion impairments and independence with sit-to-stand transfers and walking. Interviews showed multiple staff members observed the bruising over several days, with some describing it as worsening and moving around the right eye. The resident’s sister stated she noticed the bruise during a visit and reported it to the DON on 3/23/26. An ARNP stated staff should notify her immediately when unexplained bruising is found on the face or head and said the 8-day delay was inappropriate. Staff interviews indicated nurses should document the bruise, complete an incident report, and notify the doctor and family, while the DON stated she first became aware of the situation when the sister reported it. The facility policy directed immediate notification of the resident, physician, and legal representative or family member when an accident results in injury with potential for physician intervention.
Incomplete Hospital Transfer Documentation in Resident Records
Penalty
Summary
The facility failed to maintain a complete medical record for 2 of 4 sampled residents by not keeping copies of hospital transfer documentation in the clinical records. Resident #4 had a BIMS score of 15 on the MDS, indicating she was cognitively intact, and required staff dependence for transfers, did not walk, and had diagnoses including malnutrition, a pressure ulcer, and paraplegia. A progress note documented that an ambulance transported Resident #4 to the hospital, and the resident later stated she required a mechanical sling lift with two-person assistance for all transfers and that her last hospitalization was for an infection. Resident #8 also had a BIMS score of 15 and diagnoses of paraplegia, diabetes, and anxiety. A health status note documented that Resident #8 entered the local hospital for sepsis and a UTI. The DON stated the nurse on shift failed to copy the transfer paperwork sent with Resident #4 and Resident #8 during their hospitalizations, and staff interviews identified the documents that should accompany a resident to the hospital, including the Resident Transfer Sheet/Record, MAR, TAR, immunization records, advance directives, and pertinent lab or x-ray results. During interview, the DON reported she could not locate the hospital transfer paperwork for either hospitalization and noted the hospital retained some documentation from Resident #4's transfer.
Delayed Transmission of DRNA Assessment
Penalty
Summary
The facility failed to ensure timely transmission of the Discharge Return Not Anticipated (DRNA) assessment for Resident #34. Record review showed the resident discharged from the facility on 11/21/25, the DRNA assessment was completed on 11/26/25, and it was not locked until 3/24/26. The MDS Assessment History showed iQIES accepted the DRNA record on 3/24/26, and a Batch Report dated 3/25/26 documented the acceptance of the assessment. During interview, an LPN stated she believed the discharge record remained marked not to submit because the resident used a Medicare Advantage plan, and she normally waited for the DON to sign off on MDS records before transmitting them each week. The CMS LTC RAI Manual directed that the DRNA be transmitted within 14 days of the completion date, but this assessment was transmitted 118 days after the required completion date.
Inaccurate MDS Diagnosis Coding
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when it coded schizophrenia on the MDS without current supporting documentation showing the diagnosis was active or directly related to the resident’s current status. Resident #7’s admission MDS documented intact cognition with a BIMS score of 15/15 and listed active diagnoses of generalized anxiety disorder, depression, and agoraphobia with panic disorder, along with antianxiety and antidepressant medications. The record also included a 1990 hospital discharge summary showing schizophrenia, residual type, and schizoid personality disorder, but that document did not show current treatment with quetiapine at that time. Later behavioral health notes documented quetiapine prescribed for major depressive disorder, PTSD, and GAD, and a therapist visit note listed GAD, schizoid personality disorder, and agoraphobia with panic disorder. Facility provider visit notes listed an active problem list but did not include a current diagnosis of schizophrenia or schizoid personality disorder, even though quetiapine remained ordered. The quarterly MDS documented a new diagnosis of schizophrenia and antipsychotic medication use, but it lacked documentation of active delirium, behaviors, hallucinations, or delusions. During interviews, the PMHNP stated she had started quetiapine for panic-type anxiety, agoraphobia, and PTSD, had seen the old 1990 schizophrenia documentation, but had not diagnosed the resident with schizophrenia or schizoid personality disorder and did not consider those diagnoses relevant to the resident’s current condition. The LPN stated she coded schizophrenia on the MDS after receiving the old records and did not verify whether the diagnosis remained current. The DON stated she entered the quetiapine order using the 1990 schizophrenia diagnosis, later confirmed there was no documentation supporting schizophrenia, and identified the MDS entry as a coding error.
Failure to Notify Providers of Critical Blood Sugars and Assess Unexplained Head Injury
Penalty
Summary
The facility failed to ensure clinical monitoring and physician notification for critical blood glucose values for Resident #5. The resident’s MDS documented a BIMS score of 15, indicating she was cognitively intact, and noted diagnoses including diabetes, fracture, and long-term insulin use. Her blood sugar summary showed multiple readings below 60 mg/dL and above 450 mg/dL, including values of 58, 461, 483, 55, 43, 457, and 515 mg/dL. The record review found no documentation in the progress notes that the provider was notified of these abnormal results. Resident #25 also had repeated severe hyperglycemia without documented physician notification. The resident’s MDS documented diagnoses including type 2 diabetes mellitus with diabetic neuropathy, schizoaffective disorder, chronic kidney disease, heart failure, and obesity. The EHR progress notes lacked documentation that the physician was notified of blood glucose readings above 450 mg/dL, including 480, 483, 510, 539, 522, and 533 mg/dL. During interview, the DON stated that staff were expected to notify the physician when blood sugars were outside parameters, and later confirmed the chart lacked documentation of physician notification. The facility also failed to perform neurological assessment and timely follow-up for Resident #17 after an unexplained bruise was found on the head/face. The resident’s MDS documented severe cognitive loss, hallucinations, behaviors toward others, rejection of care, and diagnoses of Alzheimer’s disease and non-Alzheimer’s dementia. Staff discovered a bruise to the right eyebrow and documented it in a progress note, but the record lacked documentation of further assessment or neurological assessment for 8 days. Multiple staff later reported seeing the bruise over several days, and the DON stated the normal process was to measure the area, document an incident report, and place the resident on alert charting for observation and vital signs, but those steps were not documented at the time the bruise was first identified.
PNA Assisted Resident With Dysphagia and Coughing During Meals
Penalty
Summary
The facility failed to ensure that a resident with dysphagia and a high risk for aspiration was fed only by licensed or certified staff. Resident #20’s MDS identified a mechanically altered diet, and the care plan directed assistance with eating and monitoring for signs and symptoms of aspiration or difficulty swallowing. A video swallow study documented coughing during meals, a diagnosis of dysphagia, and recommendations for pureed food with mildly thick liquids and strict safe swallow precautions, including small bites and sips and a slow rate of intake. Despite these findings, the PNA-Resident Dining assessment determined that Resident #20 could eat with the assistance of a PNA. Staff interviews showed PNAs assisted the resident with meals on a regular basis, and one PNA reported the resident coughed after every drink and that she did not report the coughing to the nurse. The DON stated the facility did not have residents that PNAs could not assist, and later stated a PNA may assist if Speech Therapy approved, while also expecting the PNA to get a nurse if the resident started choking or coughing. The facility policy stated residents with recurrent lung aspiration or difficulty swallowing are to be fed only by nurses, nurse aides, or other licensed health professionals.
Failure to Perform Hand Hygiene and Proper Commode Cleaning
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during the cleaning of a commode for Resident #3. Resident #3 had a BIMS score of 15 out of 15 on the MDS dated 1/13/26, indicating intact cognition, and the care plan identified a risk of chronic urinary disturbance with interventions to encourage commode use and assist as needed. During an initial interview, Resident #3 stated that only one CNA washed hands after emptying her commode bucket, that only 2 to 3 CNAs wore gloves to clean the bucket, and that she did not see staff wash hands or use hand sanitizer afterward. She also reported that staff sometimes refilled her water pitcher immediately after handling the commode. During observation, Staff D, a CNA, assisted Resident #3 with the commode and removed a pan containing visible bowel movement. Staff D placed the dirty pan half-tipped on the roommate’s toilet seat, removed gloves, and opened a drawer to get a plastic bag without performing hand hygiene. Staff D then put on new gloves, placed the dirty pan in the bag, returned it to the commode, changed gloves again without hand hygiene, and carried the commode more than 60 feet to the dirty utility room. There, Staff D rinsed the pan but visible bowel movement remained in three places on the rim, removed gloves and left the room without hand hygiene to get cleaning chemical, returned with a glove on only one hand without washing hands, sprayed the pan, and then washed hands for about five seconds. An LPN verified that Staff D left the utility room without washing hands and that visible bowel movement remained on the pan, and the DON stated that best practice is hand hygiene after glove removal and that the facility policy required a 15 to 20 second hand wash.
Failure to Timely Complete SCSA MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) Assessment in a timely manner for a resident who elected hospice services. The resident was referred for hospice care services, and the family agreed to a hospice consultation. The hospice care provider scheduled an onsite visit, and the resident was admitted to hospice care services. However, the facility did not document hospice as the primary payer in the Electronic Healthcare Record (EHR) census detail page, and the SCSA MDS was not completed within the required timeframe. Interviews with facility staff revealed a lack of awareness and communication regarding the completion of the SCSA MDS. The MDS Coordinator, responsible for completing all required MDS assessments, acknowledged the oversight and stated that the SCSA MDS should have been completed by a specific date. The Director of Nursing (DON) was unaware of the required completion timeframe and needed to consult with the MDS Coordinator. The failure to complete the SCSA MDS within the required timeframe was acknowledged by the MDS Coordinator, who admitted the oversight.
Failure to Update Care Plan for Hospice Services
Penalty
Summary
The facility failed to revise and implement interventions on the comprehensive Care Plan to include hospice services for a resident who was on hospice care. The resident, identified with moderate cognitive impairment, non-traumatic brain dysfunction, heart failure, diabetes mellitus, and non-Alzheimer's dementia, had a Hospice Election Packet signed by a family member with a start of service date. However, the Care Plan initiated for the resident did not include a focus area for a terminal prognosis with the election of hospice care services, nor did it provide interventions directing staff on the care to be provided. During an interview, the MDS Coordinator acknowledged that the Care Plan should have been updated to reflect the election of hospice care services. The Director of Nursing (DON) confirmed that the MDS Coordinator is responsible for updating and revising the Care Plan.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to utilize proper food handling procedures to prevent potential cross-contamination of food, which could lead to foodborne illness. During the preparation of pureed meals, Staff B, a dietary staff member, was observed using a single glove on her left hand to remove a green lid from a container holding buttered bread slices. Staff B then reached into the container with the same gloved hand to remove four slices of buttered bread, which were placed into a food processor with green beans. This action did not adhere to proper food handling practices, as it posed a risk of cross-contamination. During an interview, Staff C, the Dietary Manager, acknowledged observing Staff B's actions and confirmed that Staff B should have used tongs to handle the bread, as previously instructed. It was also revealed that the facility lacked a specific policy for food handling and instead followed the current Iowa Food Code. The Iowa Administrative Code mandates that food must be processed, stored, and distributed in a manner that protects it from contamination, including cross-contamination and allergen cross-contact.
Inaccurate MDS Assessment for Resident's Feeding Tube Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment accurately reflected the health status of a resident. The MDS for this resident incorrectly documented the use of a feeding tube, despite observations and staff interviews confirming that the resident did not have a feeding tube. The Director of Nursing confirmed that the resident had never had a feeding tube, and the MDS coordinator acknowledged the error in coding. Additionally, the facility lacked a specific policy for completing MDS assessments, relying instead on the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual.
Inaccurate Staffing Reporting to CMS
Penalty
Summary
The facility failed to completely and accurately report the required staffing information to the Centers for Medicare and Medicaid Services (CMS) for Fiscal Year Quarter 1. The Payroll Based Journal (PBJ) report, compiled by CMS, indicated excessively low weekend staffing. However, a review of daily staffing sheets and nursing department schedules showed staffing levels over 2.0 hours per resident per day. Observations from March 24 to March 27, 2025, revealed that residents were well cared for, being out of bed, dressed, clean, and well kempt, with no odors and made beds. During an interview, the Administrator, Director of Nursing (DON), and Human Resources explained that the PBJ data is submitted by their corporate office, and they do not receive a preliminary report to review for accuracy.
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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