Park View Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sac City, Iowa.
- Location
- 601 Park Avenue, Sac City, Iowa 50583
- CMS Provider Number
- 165343
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Park View Rehabilitation Center during CMS and state inspections, most recent first.
Delayed Call Light Response: Multiple residents reported and logs confirmed call lights were often unanswered for more than 15 minutes, with some waits lasting 30 minutes to over an hour. Residents needing assistance with toileting and transfers described waiting long periods for help, and staff acknowledged that call lights sometimes exceeded 15 minutes, including when agency staff did not receive pagers at the start of shift.
Food items were found open and undated in refrigerators and freezers, and several dry storage items were past their best by dates. During lunch service, an CDM handled bread and sliced meat while wearing gloves but did not perform hand hygiene during the observed food prep process, and the facility policy required hand hygiene and dating of prepared foods.
The facility failed to have the required QAPI committee members attend quarterly meetings. Review of the QAPI attendance record showed no IP present at the QA meetings over several months, and the Administrator confirmed the IP was not present during that period. The facility's QAPI policy stated the committee members must meet at least quarterly.
Failure to provide scheduled bathing and ordered edema wear: Three residents with intact or near-intact cognition reported receiving fewer baths/showers than scheduled, and EHR review showed missed baths with no refusals documented. One resident also lacked prescribed edema wear despite a physician order to apply it in the morning and remove it in the evening. Staff and the DON gave conflicting accounts about the edema wear, and staff reported bathing was not being completed as scheduled.
A facility failed to consistently provide restorative ROM services for two residents with limited mobility and dependence in ADLs. One resident reported therapy had stopped after admission and wanted therapy again, while the other said staff were frequently pulled to the floor. EHR review showed restorative tasks were scheduled, but documentation reflected missed or incomplete sessions, and staff said restorative aides were often reassigned to CNA duties, preventing the tasks from being completed as written.
Infection control practices were not followed when a dietary aide entered a COVID-positive resident’s room without PPE and delivered a meal tray, a CNA removed a sit-to-stand lift from a COVID-positive resident’s room without cleaning it, and wound care for a resident with an MDRO and open wounds was performed without EBP. The DON confirmed the residents’ COVID status and that equipment should be cleaned after use, while the IP stated the resident with wounds was not placed on EBP and that CDC guidance was not used to determine the need for EBP.
A cognitively impaired resident with moderate impairment, documented as confused and forgetful, was assisted by the SSD in completing a Medicaid application that involved cashing out a final expense life insurance policy to reduce assets. The SSD communicated with the resident’s POA by email about the need to spend down assets and stated the resident was agreeable if the POA was as well, but the POA questioned the cash-out and reported telling the SSD to wait until she could contact the insurer. Despite this, a cash surrender form was completed with the resident’s signature and the SSD as witness, without documentation of the resident’s cognitive status at the time of signing and without clear documentation of POA consent. The POA later learned the policy had been cancelled and stated the resident did not want it cancelled and was not in a condition to make that decision.
A resident with moderate cognitive impairment and multiple medical conditions, including atrial fibrillation, cirrhosis, arthritis, and a history of repeated falls, was prescribed PRN Lorazepam for anxiety, initially ordered every 4 hours and later changed to every 2 hours PRN without a documented rationale or end date. The MAR showed the PRN Lorazepam was given 19 times in one month, with 11 doses documented as ineffective. The DON reported that the family did not want the resident on psych meds and that staff attempted non-pharmacological interventions first, but acknowledged there was no documented rationale or end date for continuing the PRN Lorazepam beyond 14 days, contrary to facility policy requiring physician documentation for extended PRN psychotropic use.
A resident with moderate cognitive impairment, multiple comorbidities, and a history of repeated falls was care planned as being at risk for falls, with an intervention to wear gripper socks in bed. The resident experienced multiple falls, including being found on the floor between the bed and wall and later on the floor by a dresser with a left arm skin tear, despite only having grippy socks as a relevant intervention at the time. Post-fall Neurological Evaluation Flow Sheets initiated after these events contained multiple missed and incomplete entries over the required 72-hour monitoring period, with several time points left blank or marked only as sleeping, contrary to the facility’s fall occurrence policy that required scheduled neuro checks with vital signs and documentation after each fall.
A resident with severe cognitive impairment and a history of stroke developed worsening pressure ulcers that were not managed according to professional standards. Despite ongoing communication with the PCP and wound center, there was confusion about wound clinic appointments, lack of timely follow-up, and insufficient escalation of care as the wounds deteriorated. The resident was ultimately hospitalized with sepsis and acute respiratory failure, with the wound identified as a likely source of infection. Staff interviews revealed gaps in wound care knowledge and communication.
A resident with cognitive impairment and a high fall risk suffered multiple falls resulting in bilateral elbow fractures and facial lacerations after the pressure alarm intended to alert staff failed to sound on two occasions. Staff did not determine why the alarm malfunctioned, and the resident had a known history of disabling or moving the alarm, but this was not effectively addressed, leading to inadequate supervision and preventable injuries.
A resident with severe cognitive impairment and a history of stroke experienced worsening pressure ulcers. Although the physician was notified of the deterioration, there was no documentation that the resident's representative was informed, as required by facility policy. A family member later reported not being notified about the change.
The facility failed to develop comprehensive care plans for several residents, omitting target behaviors related to psychotropic medication use and non-pharmacological interventions. One resident with moderate cognitive impairment and others with normal cognition had care plans that did not address their specific needs, despite documented behaviors and medication use. The facility acknowledged these deficiencies and was in the process of updating care plans.
The facility failed to update Care Plans for two residents, leading to deficiencies in care. One resident's Care Plan did not reflect changes in weight management and oxygen use, while another resident's Care Plan lacked documentation of a low bed as a fall prevention measure. Staff acknowledged the discrepancies, attributing them to staffing changes and lack of specific policy for Care Plan revisions.
A facility failed to maintain an emergency tracheostomy kit with an obturator at the bedside for a resident with a tracheostomy, as required by the care plan. The kit was instead kept at the nurses' station, and staff communicated its location during reports. The DON cited the resident's independence and tendency to fiddle with items as reasons for not keeping the kit in the room. The facility lacked a tracheostomy policy, contributing to the deficiency.
A CNA failed to perform proper hand hygiene while assisting three residents during meal service, using the same hand to feed multiple residents and not sanitizing hands after wiping mouths or touching straws, contrary to facility policy.
Delayed Call Light Response
Penalty
Summary
The facility failed to provide nursing staff to assure resident safety by not responding to call lights in a timely manner for 4 of 6 residents reviewed: Resident #27, Resident #53, Resident #11, and Resident #15. The facility had a census of 45 residents. The report included resident council meetings, EHR review, document review, resident interviews, and staff interviews showing repeated delays in call light response times, with multiple calls lasting longer than 15 minutes and some lasting much longer. Resident #27’s MDS documented a BIMS of 13 and dependence on staff for toileting hygiene, lower body dressing, and taking off footwear. The resident stated he had waited up to 45 minutes for a call light to be answered. The facility’s call light log for the resident showed several response times over 15 minutes, including 19 minutes and 53 seconds, 22 minutes and 24 seconds, 38 minutes and 26 seconds, 19 minutes and 40 seconds, 30 minutes and 56 seconds, and 26 minutes and 8 seconds. Resident #53, who had recently been admitted and was documented as alert to person, place, time, and staff names and faces, stated call lights had taken up to an hour to be answered and that he had waited 45 minutes on a bed pan and became incontinent of stool while waiting. The call light log for this resident showed numerous delays, including times of 29 minutes and 25 seconds, 25 minutes and 16 seconds, 32 minutes and 56 seconds, 1 hour, 1 minute and 38 seconds, 40 minutes and 6 seconds, and other delays over 15 minutes. Resident #11’s MDS documented a BIMS of 14 and need for two-plus physical assistance with transfers and toileting, and the resident stated call lights sometimes took up to 30 minutes. Resident #15’s MDS also documented a BIMS of 14 and need for two-plus physical assistance with transfers and toileting, and the resident stated call lights often took longer than 15 minutes and at times almost 30 minutes. Staff interviews confirmed that call lights were monitored through pendants, pagers, and a central screen, but staff also stated that call lights did go longer than 15 minutes, that agency staff sometimes did not receive pagers at the start of shift, and that staff were supposed to complete slips when call lights exceeded 15 minutes. The DON stated she had heard call lights lasted longer than 15 minutes, that staff filled out slips, that agency staff not picking up pagers had been reported, and that call lights should be answered in 15 minutes or less.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
Food was not prepared in accordance with professional standards during meal service and food storage. Observation of the kitchen found multiple open food items that were not dated, including a 16 oz. container of parmesan cheese, a bag of diced chicken, a large bag of bacon bits, a large bag of chicken cordon bleu, a plastic container with about 10 biscuits, and a large bag of cinnamon rolls. In the freezer, a box of pre-cooked hamburgers and a box of pre-cooked omelets were open, with the box tops cut away and food items stored on the shelf above them. In dry storage, several items were found past their best by dates, including cans of chili beans, butter beans, tomato paste, and a jar of pizza sauce. During lunch meal service, Staff N, the Certified Dietary Manager, handled food while wearing gloves but did not perform hand hygiene during the observed food preparation process. Staff N retrieved butter, bread, and sliced meat, opened the bread bag, removed bread with one hand, buttered it, opened the sealed meat bag, removed several slices of meat, placed some meat back into the bag, cut the bread in half, and then plated the sandwich for the dining room. The facility policy stated that employees must perform hand hygiene prior to handling food and maintain safe food handling practices, and that all foods prepared in operation must be covered and labeled with the date of preparation prior to storage.
QAPI Committee Lacked Required IP Attendance
Penalty
Summary
The facility failed to have the necessary required members attend quarterly Quality Assurance and Performance Improvement (QAPI) meetings. Review of the facility's QAPI Committee Attendance Record for August 2025 through February 2026 showed that no Infection Preventionist (IP) attended the Quality Assurance meetings during that period. The facility reported a census of 45 residents. During interview, the Administrator stated that the facility did not have an IP until the new DON came to work at the facility, and later confirmed that the IP was not present at the meetings from August of last year through February of this year. Review of the facility's QAPI policy with a revision date of 10/2023 showed that the members of the QAPI committee must meet at least quarterly.
Failure to Provide Scheduled Bathing and Ordered Edema Wear
Penalty
Summary
The facility failed to provide an opportunity for bath or shower and failed to apply edema wear as ordered for 3 of 3 residents reviewed. Resident #4’s MDS documented a BIMS of 13 and need for partial/moderate assistance with bathing. The resident stated she was supposed to receive baths on Tuesdays and Thursdays and wanted a shower twice a week, but said she had not had edema socks in a couple of months. Observation of the resident’s bathroom on 3/10/26 and 3/11/26 found no compression socks present, and the resident was wearing thick black socks just over the ankle. Resident #4’s EHR and MAR-TAR contained a physician’s order, started 12/9/25, to apply edema wear in the morning and remove it in the evening. The EHR bath record for the last 30 days showed baths on 2/11, 2/17, 2/19, 2/24, 3/4, 3/5, and 3/10, with no refusals documented. The care plan included assisting the resident with shower/bathing per schedule. Staff gave conflicting statements about the edema wear, with one CNA stating she had never taken it off and had not been told the resident required it, while an RN stated she had removed it the night before or the night prior. The DON stated nurses were expected to document application of edema wear and ensure it was removed in the evening per the physician’s order. Resident #27’s MDS documented a BIMS of 13 and dependence on staff for toileting hygiene, lower body dressing, and footwear removal. The resident stated he was supposed to get 2 showers a week, usually on Monday and Thursday, but mostly received only one. The EHR task record showed baths on 2/12, 2/16, 2/19, 2/23, 3/2, and 3/9, with missed baths on 3/2 and 2/26 and no refusals documented. Resident #11’s MDS documented a BIMS of 14 and need for two-plus physical assistance with transfers and bathing. The resident stated she had only been receiving one shower a week instead of twice a week, and staff interviews confirmed baths were not being completed twice weekly, with staff reporting frequent pulling to the floor and a broken bathtub that had been out of service for about a year.
Restorative ROM Services Not Consistently Provided
Penalty
Summary
The facility failed to provide range of motion (ROM) services to residents with limited ROM to help maintain function and prevent further decrease in ROM or development of contractures for 2 of 3 residents reviewed. Resident #4’s MDS documented a BIMS of 13 with no cognitive impairment and partial/moderate assistance needed for bathing. The resident stated therapy had stopped after admission, that she had previously walked with a walker, and that she now used a walker and wanted therapy again. The EHR showed restorative tasks scheduled 3 times weekly, including nu-step and lower extremity exercises, but the documentation reflected only some completed sessions and no refusals. Resident #9’s MDS documented a BIMS of 14 with no cognitive impairment and dependence on staff for toileting hygiene, showering/bathing, lower body dressing, and removing footwear. The resident stated that when someone was available, they were pulled to the floor frequently. The restorative task record showed manual resist leg press and nu-step activities were scheduled, with several entries showing the resident did not refuse, but multiple dates were documented as 0 for completion. The care plan included restorative nursing interventions to help the resident achieve and maintain optimal physical, mental, and psychosocial skills and to encourage participation in restorative programs. Staff interviews indicated the restorative program was not consistently carried out as written because staff assigned to restorative were frequently pulled to work as CNAs. A CNA/CMA/bath aide stated she filled in for the restorative aide when off but could not complete restorative appropriately because she was often pulled to the floor. The restorative aide stated that over the prior 3 weeks either she or the fill-in staff were pulled daily, and that a 0 on the restorative task meant the task was not completed because she was working as a CNA. The RDO/PTA and DON acknowledged the restorative task documentation did not appear to have been charted as completed according to the written task, and the DON stated she expected the restorative program to be followed as written.
Infection Control Failures With PPE, Equipment Cleaning, and EBP
Penalty
Summary
The facility failed to implement infection prevention and control practices when Staff A, a Dietary Aide, entered Resident #37’s room while the resident was on Transmission-Based Precautions for COVID-19 without donning PPE first. Staff A placed the meal tray on the bedside table within the resident’s reach, exited the room, and then used hand sanitizer. The DON confirmed the resident had tested positive for COVID-19 and remained on Transmission-Based Precautions during the period of the observation, and the Administrator stated all staff should wear PPE when entering a room where a resident is COVID-19 positive. The facility also failed to clean reusable equipment between resident uses when Staff B, a CNA, brought a sit-to-stand mechanical lift out of Resident #15’s room after use and did not clean the lift before taking it to the end of the south hall and placing it in the living area. Resident #15 was documented as COVID-19 positive, and the DON and Administrator both confirmed that mechanical lifts should be cleaned after use in a room requiring PPE. The facility further failed to follow current CDC guidance for Enhanced Barrier Precautions during wound care for Resident #11. Resident #11 had a BIMS of 14, an active MDRO diagnosis, and wounds to the right ankle and right lower shin with physician-ordered dressing changes. During observation, the ADON performed the wound care using hand hygiene and gloves but did not apply a gown, and no EBP sign was posted outside the room. The DON, who served as Infection Preventionist, stated Resident #11 was not on EBP and indicated she did not refer to CDC guidance for determining when EBP was required; Staff G acknowledged the resident should have had EBP in place related to the wounds.
Failure to Involve POA in Financial Decision-Making for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to allow a resident’s representative/POA to assist a cognitively impaired resident with decision-making regarding a significant financial decision related to Medicaid eligibility. The resident had a BIMS score of 10, indicating moderate cognitive impairment, and progress notes over several days documented that he was alert only to person (and sometimes place) and was confused and forgetful. The Social Services Director (SSD) worked directly with the resident on a Medicaid application and identified a final expense life insurance policy with a cash value of approximately $3,277.81 and a face value of $15,000, which the SSD believed would likely need to be cashed out to reduce the resident’s resources below $2,000. The SSD documented that the resident was okay with cashing out the policy if the POA agreed, and emailed the POA explaining that the resident needed to be below $2,000 in assets and that she could assist the resident with this. The POA questioned what was meant by “cashing out” the policy and indicated she needed to handle this herself, later stating she told the SSD to wait until she could contact the insurance company. Despite this, an insurance company form requesting cash surrender value was completed with the resident’s signature and the SSD as witness. The clinical record did not contain documentation of the resident’s cognitive status at the time he signed the cash surrender form, and the SSD acknowledged she had no documentation of dates or times of her discussions with the POA. The POA later reported that the resident did not want to cancel his life insurance policy, that his mental status had declined and he was not in a condition to make that decision, and that she learned from the insurance company that the policy had been cancelled. The SSD also stated she was not aware of other available options for handling the life insurance policy in the Medicaid spend-down process.
Failure to Obtain Required Rationale and End Date for Extended PRN Psychotropic Use
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication was only continued beyond 14 days with a provider’s written rationale and end date for one resident. The resident had moderate cognitive impairment, with a BIMS score of 10, and diagnoses including atrial fibrillation, cirrhosis, arthritis, and repeated falls. A new prescription dated 9/25/25 ordered Lorazepam 0.25 mg by mouth every 4 hours PRN for anxiety, and on 10/2/25 the order was changed to every 2 hours PRN without any documented rationale for continuing the PRN psychotropic or specifying an end date. The October MAR showed the PRN Lorazepam was administered 19 times through the 28th, with 11 of those administrations documented as ineffective. In an interview, the DON stated the family did not want the resident on psych medications and that staff tried all non-pharmacological interventions before administering medications per the family’s wishes, and acknowledged she did not think a rationale or end date was provided to continue the PRN Lorazepam, despite facility policy limiting PRN psychotropic use to 14 days unless extended by the physician with documented rationale.
Failure to Implement Fall Interventions and Complete Post-Fall Neuro Assessments
Penalty
Summary
The deficiency involves the facility’s failure to implement adequate fall-prevention interventions and to complete required neurological assessments after falls for one resident. The resident had moderate cognitive impairment, required partial to moderate assistance with multiple ADLs, and had diagnoses including atrial fibrillation, cirrhosis, arthritis, and a history of repeated falls. The care plan identified the resident as at risk for falls related to impaired cognition and recent falls, with an intervention that the resident wear gripper socks in bed. Progress notes documented that on one occasion the resident was found on the floor between the bed and the wall, gripping the curtains, with the bed in the lowest position and grippy socks on, and the resident was only able to answer simple yes/no questions and could not explain what he had attempted to do. On another occasion, the resident was found on the floor by his dresser, leaning on his left arm, reporting left arm pain and having a 4 x 3 cm skin tear near the left elbow, and it required three staff with a gait belt to transfer him to a wheelchair. The facility also failed to complete neurological assessments as required by its fall occurrence policy following these falls. After the first fall, the Neurological Evaluation Flow Sheet initiated that evening lacked completed assessments at several scheduled times, with multiple entries indicating the resident was sleeping and missing vital signs and other required data at specific hours. Some entries documented the resident as sleeping but still included vital signs and pupil assessments, creating inconsistencies. Following a later fall in which the resident was found sitting on the floor with his wheelchair behind him, another neurological flow sheet was initiated, but it lacked completed assessments at additional scheduled times, again marked as sleeping. The facility’s policy required neurological evaluations with vital signs initially, then every 30 minutes times four, every hour times four, and then every eight hours times nine (for a total of 72 hours), with documentation and monitoring for 72 hours post-fall, which was not fully carried out for this resident.
Failure to Provide Timely Wound Care and Follow-Up
Penalty
Summary
A resident with a history of stroke, right-sided hemiplegia, and severe cognitive impairment developed pressure ulcers on both buttocks. The care plan identified the resident as high risk for skin integrity issues and included multiple interventions such as medication administration, wound care per physician orders, use of barrier creams, and regular skin assessments. Despite these interventions, documentation showed that the resident's wounds deteriorated over time, with increasing drainage, foul odor, and the development of eschar. The facility staff communicated with both the primary care provider (PCP) and the wound center physician regarding the resident's condition, but there was confusion and lack of clarity about wound clinic appointments and follow-up care. On several occasions, staff noted worsening wound conditions and communicated these findings via fax to the physicians. However, there was a failure to ensure timely follow-up and coordination between the facility, the PCP, and the wound center. For example, the facility believed the resident had a wound clinic appointment on a certain date, but no such appointment was scheduled, and there was no documentation of follow-up or notification to the wound center physician about the deteriorating wound. Weekly skin assessments continued to show worsening wounds, but the facility did not escalate care or ensure the resident was seen sooner by the wound specialist, even when staff hoped for more urgent intervention. Ultimately, the resident developed severe symptoms including respiratory distress, fever, and a large buttock ulcer, leading to hospital admission. Hospital records indicated the resident was septic with acute respiratory failure, and the wound was identified as a likely source of infection. Staff interviews revealed gaps in wound care knowledge and assessment, as well as uncertainty about wound clinic appointments and communication with providers. The facility's failure to provide treatment and care in accordance with professional standards, including timely follow-up and coordination with wound care specialists, contributed to the resident's decline.
Failure to Ensure Effective Fall Prevention and Supervision
Penalty
Summary
A deficiency occurred when a resident with impaired cognitive function and a known risk for falls experienced multiple falls within a short period, resulting in significant injuries including bilateral elbow fractures and facial lacerations. The resident was equipped with a pressure alarm intended to alert staff when attempting to get up without assistance. However, on two separate occasions, the alarm failed to sound, and staff did not determine the cause of the malfunction. The resident had a documented history of turning off or moving the alarm, but this was not effectively addressed at the time of the incidents. On the first occasion, the resident was found in another room after getting up unassisted, resulting in a right elbow fracture and a laceration near the right eye that required sutures. The alarm did not sound, and staff were unaware of the resident's movement until after the fall. On the following day, the resident fell again, this time fracturing the left elbow and sustaining another facial laceration. Again, the pressure alarm did not activate, and the fall was unwitnessed. Staff interviews confirmed that the alarm was either not turned on, had been disabled by the resident, or was otherwise ineffective, but no investigation into the alarm's failure was conducted at the time. Documentation and staff interviews revealed that the resident's fall risk was known, and interventions such as bed and door alarms were in place or considered. Despite these measures, the lack of adequate supervision and failure to ensure the functionality of the alarm system directly contributed to the resident's repeated falls and injuries. The facility's policy required evaluation and implementation of interventions to minimize fall risk, but these were not effectively executed in this case.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in the resident's condition, specifically the deterioration of pressure ulcers. The resident in question had a history of stroke with right-sided hemiplegia, severe cognitive impairment, and was at risk for skin integrity issues due to immobility and medication use. Documentation showed that the resident developed pressure ulcers on both buttocks, with one area worsening over time as noted in weekly skin assessments. The physician was notified of the changes via fax, but there was no documentation that the resident's representative was informed of the wound deterioration. A family member later reported to the facility that she had not been notified about the worsening of the resident's wounds. Staff interviews confirmed that wound assessments were conducted and physicians were notified, but the clinical record lacked evidence of timely notification to the resident's representative. The facility's policy required immediate notification of significant changes in a resident's status to the resident, their physician, and their representative, but this was not followed in this instance.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, which did not identify target behaviors related to the use of psychotropic, antianxiety, and antidepressant medications, nor did they include non-pharmacological interventions. For Resident #4, the care plan lacked focus areas with goals and interventions related to the diagnosis of dementia, despite the resident's moderate cognitive impairment and use of antipsychotic and antidepressant medications. The care plan also failed to address target behaviors and side effects of the medications. Resident #15, who had normal cognition, was prescribed multiple medications for anxiety and depression. The care plan did not identify target behaviors related to the use of these medications, despite documented behaviors such as complaints, anger, and refusal of care. Similarly, Resident #16, with normal cognition and diagnoses including anxiety disorder and depression, had a care plan that did not identify target behaviors related to the use of psychotropic medications, even though the resident experienced feelings of depression and loneliness. Resident #22, with normal cognition and diagnoses of anxiety, depression, bipolar, and psychotic disorder, also had a care plan that failed to identify target behaviors related to the use of psychotropic medications. The facility's policy required care plans to be reviewed and updated for interventions related to identified behaviors or symptoms of the diagnosis, but this was not done. The facility acknowledged the lack of target behaviors and non-pharmacological interventions in the care plans and was in the process of updating them to provide more individualized focus areas, goals, and interventions.
Care Plan Deficiencies in Resident Interventions
Penalty
Summary
The facility failed to review and revise the Care Plan interventions for two residents, leading to deficiencies in care. For one resident, the Care Plan was not updated to reflect a change from unexpected weight gain to weight loss, despite significant weight loss being documented by the dietitian. Additionally, the Care Plan did not reflect the discontinuation of daily weights, which was ordered by the primary care provider. The resident's oxygen use was also not accurately reflected in the Care Plan, as it did not account for the change from continuous oxygen at 2 liters to a titrated range of 2-4 liters to maintain oxygen saturation levels. Another resident's Care Plan failed to include the use of a low bed as a fall prevention intervention, despite the resident having a history of falls and the low bed being used as a precautionary measure. Observations confirmed the use of a low bed, but this intervention was not documented in the Care Plan. Staff interviews revealed that the low bed had been in use for some time, but the Care Plan had not been updated to reflect this intervention. The Director of Nursing and the Administrator acknowledged the deficiencies in the Care Plans, noting that the Care Plans did not reflect the residents' current needs and interventions. The facility did not have a specific policy for Care Plan revisions, relying instead on the Resident Assessment Instrument manual for guidance. The lack of updates to the Care Plans was attributed to changes in staffing and the Director of Nursing covering multiple areas.
Failure to Maintain Emergency Tracheostomy Kit at Bedside
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy by not having an emergency tracheostomy kit with an obturator at the bedside. The resident, who had diagnoses including coronary artery disease, acute respiratory distress, depression, and pneumonia, was documented to have a tracheostomy and required oxygen. The care plan indicated that a spare tracheostomy should be maintained at the bedside, but observations on two separate occasions revealed the absence of the emergency tracheostomy set in the resident's room. Interviews with staff revealed that the extra tracheostomy set was kept at the nurses' station instead of the resident's room. The LPN stated that the location of the kit was communicated during nurse-to-nurse reports, but there was no policy in place to guide this practice. The Director of Nursing acknowledged the absence of the kit in the room, citing the resident's independence and tendency to fiddle with items as reasons for not keeping it bedside. The facility administrator confirmed the lack of a tracheostomy policy, contributing to the deficiency in care.
Failure to Perform Proper Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to complete proper hand hygiene during meal service, as observed on 4/24/24 at 11:30 AM. A Certified Nursing Assistant (CNA) assisted two residents to eat at the same time, using the same hand to feed both residents without performing hand hygiene in between. The CNA also wiped one resident's mouth with a napkin and then used the same hand to feed another resident, again without performing hand hygiene. Additionally, the CNA assisted a third resident with a drink and straw without performing hand hygiene before or after the task. These actions were observed for three residents during the meal service. The Assistant Director of Nursing (ADON) and infection preventionist confirmed that the facility's policy requires hand hygiene after wiping a resident's mouth or touching straws, but not necessarily after touching a resident's hand unless visibly soiled. The facility's Exposure Control/Hand Hygiene policy, reviewed on 4/24/24, mandates hand hygiene before and after direct resident contact, before and after assisting a resident with meals, and after contact with a resident's mucous membranes and bodily fluids. The observed actions of the CNA were inconsistent with these policy requirements, leading to the identified deficiency.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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