Parkview Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Wellman, Iowa.
- Location
- 516 13th Street, Wellman, Iowa 52356
- CMS Provider Number
- 165234
- Inspections on file
- 28
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Parkview Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, post-CVA deficits, dementia, aphasia, anxiety, and depression was allegedly subjected to verbal and physical abuse by an LPN in the dining area, including being told to "shut up" and being roughly pulled and escorted by the arm while calling out for food. Dietary staff witnessed the incident and recognized it as potentially abusive but did not immediately report it to supervisory staff or the Administrator, instead delaying disclosure until later that day or the following day. Although another staff member promptly reported rude verbal remarks by the LPN, the full allegation of rough handling was not brought to leadership until the next day, and the State Agency was not notified until the morning after the incident, contrary to facility policy requiring abuse allegations to be reported to the state within two hours of the allegation being made.
A resident with moderate cognitive impairment and multiple diagnoses was involved in an incident where they were found unclothed with another resident. Despite an assessment indicating the resident could not identify harmful situations or avoid exploitation, the care plan was not updated to reflect this risk or the inability to provide informed sexual consent. Staff interviews confirmed the care plan should have addressed these findings, but it was not revised accordingly.
A resident with severe cognitive impairment and a history of aggression struck another resident in the face with a walker, causing a nasal fracture. Despite known behavioral risks and care plan interventions requiring close supervision and separation from others during agitation, staff were not present in the dining room at the time, allowing the incident to occur. The injured resident, who also had cognitive impairment, experienced ongoing fear and distress as a result.
Multiple residents did not receive ordered labs, medications, or follow-up care due to failures in transcribing and implementing provider orders. Orders for routine and as-needed labs, medication administration, and specialist referrals were missed or incorrectly documented, and dictated clinic notes were not consistently reviewed by nursing staff. The facility's inconsistent processes and reliance on agency staff contributed to these deficiencies, affecting residents with complex medical needs.
Two residents were not treated with dignity and respect: one was left in stained, inadequate clothing and with unkempt hair despite care plan directives, and another experienced distress after a room search led to the removal and delayed return of personal items important to her well-being. Staff acknowledged the issues, and the facility's assessment highlighted the need for person-centered care.
Surveyors found that two residents with cognitive and physical impairments did not have their call lights within reach during multiple observations. One resident with severe cognitive impairment and multiple diagnoses had the call light on the floor or hanging on the wall, while another resident needing mobility assistance had the call light placed on a chair out of reach. Staff and the DON acknowledged the expectation for call lights to be accessible to all residents.
A resident's code status was inconsistently documented across the EHR, care plan, and IPOST binder, with conflicting indications of DNR and CPR preferences. LPNs relied on both electronic and paper sources for code status information, leading to confusion due to discrepancies. Facility policy required proper validation and documentation, but this was not consistently followed.
Staff did not consistently mop the dining room floor or clean ceiling fans, resulting in persistent sticky floors, dried liquid stains, and thick dust on fans and ceilings. Interviews revealed inconsistent cleaning routines and unclear staff responsibilities, with no formal housekeeping policy in place for common area sanitation.
Medications requiring refrigeration, including insulin pens, were stored in a refrigerator with temperatures consistently above the facility's policy range. Staff were unclear about the correct temperature requirements, and the refrigerator was poorly maintained, with the freezer compartment filled with dried ice. These actions resulted in improper storage of drugs and biologicals.
Two residents reported being treated roughly and without respect during incontinence care by a CNA. One resident with severe cognitive impairment and another with intact cognition both expressed distress over the CNA's behavior. Despite being informed, the CNA continued inappropriate actions. The facility's administrator was unaware of the incidents until reviewing notes and initially perceived the concerns as cultural differences.
A facility failed to report allegations of abuse involving two residents in a timely manner, violating its abuse prevention policy. One resident with severe cognitive impairment reported rough treatment by a CNA, corroborated by her roommate. Another resident with intact cognition also reported similar behavior by the same CNA. Despite these reports, the facility did not document or report the incidents to the State Agency as required.
A facility failed to investigate abuse allegations and separate the alleged perpetrator from residents. A resident with severe cognitive impairment and another with intact cognition reported rough and rude behavior by a CNA. Despite these reports, the facility did not document investigations or ensure the CNA was removed from resident care. The Administrator was unaware of the incidents until days later, highlighting a lack of timely response.
A facility failed to notify a resident, their representative, and the ombudsman of a discharge, as required by policy. The resident, with intact cognition and diagnoses of bipolar disorder, anxiety, and depression, was sent to the hospital for evaluation due to increasing behaviors. The facility did not document the required notifications, and the Administrator confirmed the ombudsman was not informed.
A facility failed to provide a written notice of the bed-hold policy to a resident and/or their representative during a hospital transfer. The resident, with intact cognition and diagnoses including bipolar disorder, was transferred without documented notification of the bed-hold policy, contrary to the facility's policy. The Administrator believed the nurse communicated this information, but no documentation supported this.
A facility failed to document the decision-making process and notify a resident's family about appeal rights after not allowing the resident to return post-hospitalization. The resident, with a history of bipolar disorder, anxiety, and depression, exhibited erratic behavior following ECT treatment. Staff noted the behavior was uncharacteristic, but the facility did not document the clinical decision-making or consult a provider, nor did they provide necessary appeal information to the family.
A resident with a history of bipolar disorder and intact cognition exhibited erratic behaviors after ECT treatment, including undressing in public and urinating on the floor. Despite these changes, the facility failed to notify a physician or conduct an assessment during the night, delaying emergency care until the following morning.
A resident with diabetes was discharged from an LTC facility without a comprehensive plan, resulting in a lack of home health services and medication administration. Miscommunication and inadequate documentation led to the resident going without insulin for over a week. The facility failed to ensure a smooth transition, as required by their discharge planning policy.
The facility failed to respond to call lights promptly, with residents reporting waits of 30 minutes to over an hour. A resident with a chronic wound waited over an hour for assistance, while another with heart failure experienced delays in changing clothes. A resident post-surgery reported inconsistent response times, and another with incontinence faced long waits leading to accidents. Staff acknowledged staffing issues, and the facility lacked a formal call light policy.
A resident with a Stage 4 pressure ulcer did not receive consistent treatment as ordered, with missing entries and illegible initials in the Treatment Administration Records. The resident reported missed treatments, and staff interviews confirmed lapses. An LPN failed to complete a treatment, and an RN was unable to fulfill a treatment due to contract termination. The DON expected all treatment orders to be carried out, but discrepancies in care delivery were noted.
A resident with moderate cognitive impairment and a feeding tube was observed lying flat during enteral feeding, contrary to facility protocols requiring head of bed elevation to prevent aspiration. Additionally, the supplemental formula bag was not labeled with the date and time of initiation, as required by facility procedures. These deficiencies were confirmed by both a CNA and the DON.
The facility exhibited several infection control deficiencies, including improper handling of ice scoops, uncovered transport of clean laundry, and unsanitary conditions in the laundry area. Staff interviews revealed inadequate training and a shortage of PPE, with gloves not readily accessible. The infection preventionist confirmed that glove sizes were on backorder, and policies lacked guidance on PPE management.
A resident with severe mental illness did not receive prescribed medications upon admission, leading to increased agitation and aggressive behavior. Despite having medications available, staff failed to administer them due to software defaults and communication lapses. This resulted in physical altercations with another resident and a staff member, highlighting deficiencies in medication administration and staff coordination.
The facility failed to ensure residents were treated with dignity while being provided care. One resident was observed with their face positioned directly on a catheter bag, and another resident's room had persistent urine odors and stains, indicating a lack of proper hygiene and dignity in care practices.
The facility failed to maintain a clean and odor-free environment for a resident with cognitive impairment and incontinence issues. Observations revealed strong urine odors, urine-stained sheets, and full urinals left on the floor. The Housekeeping Supervisor confirmed frequent issues with odors due to spills and wet briefs left in the room.
The facility failed to complete wound treatments as ordered for two residents. One resident with multiple diagnoses did not receive prescribed treatments for her face, scalp, wrist, and nostrils on several occasions. Another resident with significant assistance needs did not receive treatments for an abrasion and Urea Cream application on specific dates.
The facility failed to ensure adequate personal hygiene services for three residents, including providing at least two bathing opportunities per week and proper catheter care. One resident was not provided scheduled bathing opportunities and refused showers on multiple occasions. Another resident did not receive scheduled bathing opportunities and had improper catheter care. A third resident was not provided scheduled bathing opportunities and refused showers on several occasions.
Delayed Reporting of Alleged Verbal and Physical Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal and physical abuse to the State Agency within two hours of staff first becoming aware of the allegation. Resident #1, who had severe cognitive impairment with a BIMS score of 7/15 and diagnoses including CVA with right-sided weakness, non-Alzheimer’s dementia, aphasia, anxiety disorder, and depression, was the subject of the allegation. The resident ambulated with a walker and required supervision while eating. The care plan identified that the resident frequently called out with repetitive words and directed staff to ensure needs were met and then use planned ignoring to decrease unwanted behaviors. On the morning of 2/28/26, dietary staff observed interactions between an LPN (Staff A) and Resident #1 in the dining room. One dietary aide (Staff B) reported that the resident repeatedly called out, “Hey man, I’m hungry!” before breakfast was served and that Staff A told the resident to “shut up” more than once while passing by to deliver medications. Staff B further stated that Staff A told the resident, “Come on, get up!” then yanked the resident up from his dining room chair by the right upper arm, turned him away from the table in a rough manner, and forcefully escorted him out of the dining room while holding the resident’s right upper arm. Staff B stated that this looked and sounded like abuse, and also reported having heard Staff A tell the resident to “shut up” on other occasions, but she did not report the 2/28/26 incident to anyone until that evening, when another kitchen staff member told her to write a statement. Another dietary aide (Staff C) reported witnessing Staff A approach the resident near his dining room chair, yell that “they’re not ready for you, go back out,” and pull on the resident’s right forearm, causing the resident’s legs to cross before the resident sat himself down and Staff A walked away. Staff C discussed what he saw with another dietary staff that day and did not speak with the Administrator until the following day, when he was then instructed to write a witness statement. The Activities Director reported hearing Staff A tell the resident he could not enter the dining room because he was “annoying everyone else” and could return if he stopped annoying others, and immediately called the Administrator, but did not see any physical contact. The Administrator and DON were not notified of the rough handling allegation until 3/01/26, and the State Agency was notified at approximately 9:32 AM that day, more than two hours after staff first became aware of the alleged abuse on 2/28/26. This delay occurred despite a facility policy requiring all allegations of resident abuse to be reported to the appropriate state entity not later than two hours after the allegation is made.
Failure to Update Care Plan for Resident at Risk of Exploitation
Penalty
Summary
The facility failed to update the care plan for a resident to reflect their risk for exploitation, despite evidence from assessments and staff observations indicating this risk. The resident in question had a BIMS score of 8, indicating moderately impaired cognition, and medical diagnoses including metabolic encephalopathy, non-Alzheimer's dementia, depression, and adjustment disorder. The care plan had previously addressed the resident's tendency to show affection to others, but did not address the risk of exploitation or the resident's inability to provide informed sexual consent. An incident occurred in which the resident was found unclothed in another resident's bed, with both residents unclothed and kissing. Staff intervened, performed a head-to-toe assessment, and separated the residents. The facility completed a verbal informed sexual consent assessment, which revealed that the resident did not demonstrate the ability to identify harmful situations or avoid exploitation. However, the care plan was not updated to reflect these findings or the resident's inability to provide informed consent. Interviews with the Administrator, Social Services, and the DON confirmed that the care plan should have been updated to reflect the resident's risk for exploitation and inability to give informed consent, but this was not done. The facility's policy requires that care plans include measurable objectives and interventions based on comprehensive assessments, but this requirement was not met in this case.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
A resident with severe cognitive impairment and a history of sundowning and physical aggression struck another resident in the face with a walker, resulting in a nasal fracture. The aggressor's care plan identified risks for sundowning, poor impulse control, and previous aggressive behaviors, including prior attempts to hit other residents with a walker. Interventions in the care plan included anticipating needs, environmental modifications, and staff interventions to protect others, but these were not effectively implemented at the time of the incident. On the day of the incident, the aggressive resident and the victim were seated next to each other in the dining room before meal service, with no aides present in the room. Staff interviews revealed that the aggressor had previously exhibited similar behaviors, and staff were aware of the need to separate him from other residents and provide close supervision, especially during periods of agitation. Despite these known risks and care plan interventions, the resident was left unsupervised, allowing the incident to occur. Multiple staff members confirmed that the resident had attempted to hit others in the past and that interventions such as seating him near the nurse's station and providing one-on-one care were supposed to be in place. The victim, who had moderate cognitive impairment and a history of behavioral symptoms, sustained a minimally displaced nasal fracture and expressed ongoing fear and distress following the incident. The facility's abuse prevention policy required staff to provide a safe environment and monitor care to ensure residents are free from abuse or mistreatment. However, the lack of staff presence and failure to follow care plan interventions directly contributed to the resident-to-resident altercation and resulting injury.
Failure to Implement Provider Orders and Follow-Up Care
Penalty
Summary
The facility failed to carry out provider orders for multiple residents, as evidenced by missed laboratory draws, failure to administer medications as ordered, and lack of follow-up on diagnostic procedures. For several residents with chronic and acute conditions such as diabetes, heart failure, seizure disorders, and recent fractures, provider orders for routine and as-needed labs, medication administration, and specialist follow-up were not implemented as directed. In many cases, the orders were either not transcribed correctly onto the Medication Administration Record (MAR), were signed off in error, or were not acted upon at all. For example, residents with orders for routine labs every six months did not have labs collected as scheduled, and residents with orders for as-needed diuretics based on weight gain did not receive the medication when indicated by their weight records. Residents with complex medical needs, including those with recent falls and fractures, did not receive timely follow-up with specialists as ordered. In one instance, a resident who sustained a hip fracture and was discharged from the hospital with orders for orthopedic follow-up did not have the appointment scheduled, and there was no documentation of the follow-up visit. Similarly, another resident with a provider order for a sleep study due to insomnia and related symptoms did not have the study scheduled or completed, despite repeated documentation in clinic notes and nursing progress notes indicating the need for this diagnostic test. The facility's process for handling provider orders was inconsistent and lacked clear accountability. Orders communicated during provider rounds were not always transcribed or implemented, and dictated clinic notes containing new orders were not systematically reviewed or acknowledged by nursing staff. The facility's reliance on agency staff and frequent staff changes contributed to lapses in communication and follow-through. The facility's own policy required that provider orders be clearly documented, transcribed, and implemented, but this was not consistently followed, resulting in missed care interventions for multiple residents.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold residents' rights to dignity and respect for two residents. One resident with heart failure, dementia, and anxiety, and moderate cognitive impairment, was observed sitting in a common area wearing a thin, stained shirt without a bra, and with unbrushed hair. The resident reported not feeling well and having a rash on her chest. She indicated she did not have any other short sleeve shirts available. Staff initially responded by addressing the rash and later provided her with clean clothing options after being questioned about her attire. The care plan for this resident included goals to assist with self-care, encourage daily clothing changes, and maintain dignity, but these were not consistently implemented as observed. Another resident, with diagnoses including cancer, renal disease, diabetes, anxiety, and depression, and with intact cognition, reported distress after a room search resulted in the removal and misplacement of personal items, including scissors and tweezers of significant personal value. The resident stated she was told to obtain a lock box, which her family provided, but her items were lost for up to three weeks before being returned. Staff confirmed the room search was conducted for safety reasons and acknowledged the resident's upset over the loss and delay in returning her belongings. The facility assessment emphasized the importance of person-centered care and maintaining dignity, which was not fully observed in these instances.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents with cognitive and physical impairments. For one resident with severe cognitive impairment, dementia, and multiple physical diagnoses, the call light was observed on the floor or hanging on the wall, out of reach, during multiple observations. The resident was unable to access the call light to request assistance and expressed a desire for help. The care plan for this resident addressed communication needs but did not include specific instructions regarding call light accessibility. For another resident with moderate cognitive impairment and a need for assistance with mobility and self-care, the call light was found on a chair next to the resident, not within reach, while the resident was in a recliner and unable to reposition herself. The resident stated she wanted help to lie down in bed. Staff acknowledged the call light was not accessible and assisted the resident upon entering the room. The care plan for this resident did include a directive to keep the call light within reach, but this was not followed during the observed incident. The Director of Nursing confirmed that all residents are expected to have call lights accessible.
Failure to Accurately Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to accurately document and maintain a resident's cardiopulmonary resuscitation (CPR) status. Review of the resident's electronic health record (EHR) showed a profile page indicating Do Not Resuscitate (DNR) status, but the scanned EHR documents included a DNR IPOST for a different resident. Physician orders contained a verbal order for DNR status, while the care plan indicated that the resident and their responsible party requested CPR to be initiated. Additionally, the IPOST in the facility's binder reflected a CPR status, with verbal consent from the legal healthcare representative and physician signature documented. Interviews with LPN staff revealed that code status information was accessed from both the EHR profile page and a physical IPOST binder at the nurses' station, depending on the situation. The facility's policy required validation of code status orders upon admission and quarterly, with appropriate state-approved DNR forms signed before entering a No CPR order in the EHR. The inconsistency and lack of accurate documentation across multiple sources led to confusion regarding the resident's actual code status.
Failure to Maintain Clean and Sanitary Dining Room Environment
Penalty
Summary
Staff failed to thoroughly mop the dining room floor after each meal service and did not routinely clean the ceiling fans in the dining room. Observations revealed sticky floors, dried liquid stains, and a pink stain under a chair near the front entrance of the dining room, which persisted over consecutive days. Additionally, two ceiling fans closest to the entrance were covered in thick dust, with a visible ring of dust on the ceiling around the fans. These conditions were noted both after lunch and breakfast services, indicating a lack of consistent and thorough cleaning. Interviews with housekeeping staff and the Housekeeping Supervisor revealed inconsistencies in cleaning practices and uncertainty about responsibilities for cleaning the dining room and ceiling fans. Staff reported spot mopping due to scheduling conflicts with resident activities, and there was confusion about who was responsible for cleaning after dinner and for cleaning the ceiling fans. The Housekeeping Supervisor confirmed the presence of sticky floors and dusty fans and acknowledged the need for cleaning. The facility did not have a formal housekeeping policy for cleaning and sanitizing common areas, as confirmed by the Administrator.
Improper Refrigeration of Medications
Penalty
Summary
Surveyors observed that medications requiring refrigeration, including multiple insulin pens and other drugs, were stored in a medication refrigerator with temperatures consistently above the facility's policy range of 36 to 46 degrees Fahrenheit. On one occasion, the thermometer inside the refrigerator read 50 degrees. The temperature log for the month showed repeated instances of temperatures ranging from 46 to 50 degrees, with some days missing documentation entirely. Additionally, the freezer compartment was found to be almost completely filled with dried ice, except for two ice bags, indicating poor maintenance of the refrigerator. During interviews, a Registered Nurse was unsure of the exact required temperature but believed it should be around 40 degrees, while the DON stated it should be below 50 degrees but did not know the specific range. The facility's policy clearly stated that medications requiring refrigeration must be kept between 36 and 46 degrees Fahrenheit. The improper storage conditions and lack of staff knowledge regarding correct temperature requirements led to the deficiency in medication storage.
Failure to Ensure Dignity and Respect During Incontinence Care
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect during incontinence care, affecting two residents. Resident #2, who has severe cognitive impairment due to non-Alzheimer's dementia, multiple sclerosis, and diabetes, reported that a CNA was rough and mean during care. The resident's care plan emphasized the need for respectful communication due to past trauma and anxiety. An incident was reported where the CNA entered the room at night, pulled down the resident's pants without warning, and spoke harshly. The resident and her roommate expressed distress and requested that the CNA not return. Despite being informed of the issue, the CNA continued to exhibit inappropriate behavior in the resident's room. Resident #7, who has intact cognition and requires assistance with toileting hygiene, also reported that the same CNA was rude and rough during care. The resident felt that the CNA's manner was as if she was mad. Another CNA confirmed that Resident #7 had complained about being treated roughly. The facility's administrator was unaware of the specific incidents until reviewing progress notes and stated that concerns about the CNA were initially perceived as cultural differences. The administrator acknowledged that if such behavior was reported, it would warrant investigation and suspension of the staff member involved.
Failure to Report Allegations of Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of abuse for two residents, leading to a deficiency in their abuse prevention policy. Resident #2, who has severe cognitive impairment and requires assistance with toileting, reported that a CNA was rough and mean during care. The resident's roommate corroborated the account, stating that the CNA acted without warning and used harsh language. Despite these reports, the facility did not document the incident or report it to the State Agency within the required timeframe. The Director of Nursing was informed via text, but no immediate action was taken to address the situation. Resident #7, who has intact cognition and requires assistance with toileting, also reported that the same CNA was rude and rough during care. This was reported to a nurse by another CNA, but the facility again failed to document or report the incident to the State Agency. The Administrator was unaware of the severity of the situation and attributed the concerns to cultural differences, indicating a lack of communication and proper reporting within the facility. The failure to report these allegations in a timely manner is a clear violation of the facility's abuse prevention policy.
Failure to Investigate Abuse Allegations and Separate Alleged Perpetrator
Penalty
Summary
The facility failed to investigate allegations of abuse and did not ensure the separation of the alleged perpetrator from residents in two cases. Resident #2, who has severe cognitive impairment and requires assistance with toileting, reported that a CNA was rough and mean during care. The resident's roommate corroborated this account, stating that the CNA acted without warning and used harsh language. Despite these allegations, the facility did not document an investigation or ensure the CNA was removed from resident care during the shift when the incident was reported. Similarly, Resident #7, who has intact cognition and requires assistance with mobility and toileting, reported that the same CNA was rude and rough during care. Another staff member confirmed that Resident #7 had complained about the CNA's behavior. However, the facility again failed to document an investigation or separate the CNA from resident care. The Administrator was unaware of these incidents until reviewing progress notes days later, indicating a lack of timely response to abuse allegations.
Failure to Notify Resident and Ombudsman of Discharge
Penalty
Summary
The facility failed to notify a resident, their representative, and the ombudsman of a transfer or discharge, as required by policy. The resident, who had diagnoses including bipolar disorder, anxiety, and depression, was sent to the hospital for evaluation due to increasing behaviors. The Minimum Data Set (MDS) assessment indicated the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Despite the facility's policy requiring written notification in a language and manner understandable to the resident and their representative, and a copy sent to the Office of the State Long-Term Care Ombudsman, the facility did not document such notifications. The Administrator confirmed via email that the ombudsman was not notified of the discharge.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to a resident and/or the resident's representative during a transfer to the hospital. The resident, who had diagnoses including bipolar disorder, anxiety, and depression, was assessed with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. According to the facility's policy dated 11/15/22, written information regarding the bed-hold policy should be provided prior to transferring a resident to the hospital. However, during the review of the clinical records, it was found that the Health Status note dated 2/4/25, which documented the planned transfer, lacked evidence of family notification or provision of bed-hold information. Additionally, the Discharge Evaluation from the same date did not include documentation regarding the bed-hold policy. The Administrator later stated that it was her understanding that the nurse on duty communicated with the family about the discharge, which should have included bed-hold information, but there was no documentation to support this.
Failure to Document and Notify Regarding Resident's Return Post-Hospitalization
Penalty
Summary
The facility failed to ensure proper documentation and notification procedures were followed when they did not allow a resident to return after hospitalization. The resident, who had diagnoses including bipolar disorder, anxiety, and depression, was noted to have intact cognition with a BIMS score of 14 out of 15. After an electroconvulsive therapy (ECT) treatment, the resident exhibited erratic behaviors such as urinating on the floor and undressing in public areas, which were out of character according to staff interviews. Despite these behaviors, the facility did not document the clinical decision-making process regarding the resident's inability to return, nor did they consult with a provider or specify which needs they could not meet. Additionally, the facility failed to provide the resident's family with necessary information regarding appeal rights, including contact details for the entity handling such requests and assistance in completing appeal forms. Interviews with staff revealed that the resident was generally pleasant and cooperative prior to the incident, and the sudden change in behavior was unexpected. The facility's administrator admitted to lacking documentation related to the decision-making process and mistakenly believed that appeal notices were unnecessary if the resident was out of the facility for more than ten days.
Failure to Provide Timely Emergency Care for Resident with Behavioral Changes
Penalty
Summary
The facility failed to provide timely emergency services for a resident, identified as Resident #8, who exhibited a significant change in behavior following an electroconvulsive therapy (ECT) treatment. The resident, who had diagnoses of bipolar disorder, anxiety, and depression, and was noted to have intact cognition, began displaying erratic behaviors such as urinating on the floor and undressing in public areas. Despite these changes, there was no documentation of an assessment or physician notification during the night when the behaviors were first observed. Staff interviews revealed that the resident's behavior was notably different from his usual demeanor, which was typically calm and sociable. Staff members reported that the resident appeared disoriented and behaved inappropriately, yet the facility did not notify a physician or send the resident for evaluation until the following morning. The Director of Nursing acknowledged that a change in mental status should prompt immediate provider notification, which did not occur in this instance.
Inadequate Discharge Planning Leads to Medication and Service Gaps
Penalty
Summary
The facility failed to develop and implement a comprehensive discharge plan for a resident, leading to a problematic transition to a post-discharge setting. The resident, who had intact cognition and required moderate assistance with daily activities, was discharged without a clear plan for home health services or medication administration. The discharge planning process was inadequately documented, and there was a lack of communication among the facility staff, the resident's managed care organization, and the host home where the resident was placed. The resident's discharge was complicated by a recent hospitalization and a new diagnosis of diabetes mellitus requiring insulin. Despite these complexities, the facility proceeded with the discharge without ensuring that necessary services and supports were in place. The social worker involved in the discharge planning was unaware of who was responsible for setting up a physician appointment necessary for home health services, and there were issues with obtaining the correct insulin and supplies due to pharmacy and insurance complications. The case manager and host home reported significant miscommunication and lack of coordination, resulting in the resident going without insulin and other medications for over a week. The facility's policy on discharge planning was not followed, as evidenced by the absence of a documented discharge plan that addressed the resident's needs and goals. This lack of planning and communication led to a failure in providing a smooth and safe transition for the resident.
Delayed Call Light Response Times in LTC Facility
Penalty
Summary
The facility failed to respond to call lights within a reasonable amount of time, as evidenced by multiple resident reports and call light logs. Residents reported waiting from 30 minutes to over an hour for assistance, which was corroborated by call light logs showing response times ranging from 19 to 40 minutes. Resident #22, who required assistance due to obesity and a chronic wound, reported waiting over an hour on the toilet. Resident #10, with a history of heart failure and falls, experienced delays in receiving help for changing clothes. Resident #50, who needed substantial assistance due to post-surgery conditions, also reported inconsistent response times. Resident #34, with bladder incontinence, experienced long waits leading to incontinent episodes. The facility's staff, including a CNA and the DON, acknowledged that staffing issues contributed to delayed response times, with the expectation being a 15-minute response time. However, the facility lacked a formal policy addressing call light response times. Resident council minutes indicated ongoing concerns about call light response times, with some improvement noted but still dependent on the staff present. The administrator confirmed the absence of a policy and the inability to print call light logs, which were only viewable at the nursing station.
Failure to Administer Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to carry out a treatment as ordered for a resident with a Stage 4 pressure ulcer. The resident, who had diagnoses including diabetes, respiratory failure, and morbid obesity, was noted to have a Stage 4 pressure ulcer on the left ischium. The treatment plan required the application of skin prep once daily for 16 days. However, the Treatment Administration Records (TARs) for July and August showed missing entries and illegible initials, indicating that the treatment was not consistently administered. The resident reported missed treatments, and staff interviews confirmed lapses in the treatment schedule. On one occasion, a Licensed Practical Nurse (LPN) failed to complete the treatment on the specified date, and a Registered Nurse (RN) admitted to signing off on a treatment with the intention of completing it later, but was unable to do so due to termination of her contract. The Director of Nursing (DON) expressed an expectation for staff to carry out all treatment orders, highlighting a discrepancy between expected and actual care delivery. The lack of consistent treatment documentation and administration contributed to the deficiency identified by the surveyors.
Failure to Maintain Proper Tube Feeding Protocols
Penalty
Summary
The facility failed to properly manage the care of a resident with a feeding tube, specifically in maintaining the appropriate head of bed elevation during enteral feeding and labeling the supplemental formula bag with the date and time of initiation. The resident, who had a moderate cognitive impairment and required partial to moderate assistance, was observed lying flat in bed while receiving tube feeding, contrary to the care plan and facility procedures that required the head of bed to be elevated to 45 degrees during and after feeding. This oversight was noted by both a CNA and the DON, who confirmed that the resident should not be flat during feeding due to the risk of aspiration. Additionally, the facility did not adhere to its policy of labeling the enteral feeding set with the date and time it was hung. On two separate occasions, the supplemental formula bag lacked proper labeling, which was confirmed by an LPN and acknowledged by the DON. The facility's procedures for enteral feedings, dated 2019, clearly instructed staff to label the administration set and maintain the head of bed elevation to prevent aspiration, yet these protocols were not followed for the resident in question.
Infection Control Deficiencies in Laundry and PPE Management
Penalty
Summary
The facility failed to implement appropriate infection control measures in several areas, including laundry handling, ice water distribution, and environmental cleaning. Observations revealed that a hospitality aide improperly handled the ice scoop by dropping it back into the ice after filling residents' cups. Additionally, clean laundry was transported in uncovered wire baskets, and the laundry area was found to be unsanitary, with piles of laundry on the floor and dryer lint filters not cleaned as required. A bag of trash with a brown liquid substance was observed leaking onto the floor in a hallway leading to the laundry and kitchen areas, further indicating lapses in environmental cleanliness. Interviews with staff highlighted issues with training and supply management. A laundry aide admitted to separating laundry on the floor and noted that dryer filters were supposed to be cleaned twice daily, but this was not consistently done. The facility was also experiencing a shortage of personal protective equipment (PPE), specifically gloves, which were not readily accessible in all resident areas. The infection preventionist confirmed that certain sizes of gloves were on backorder, and the facility's policies did not adequately address PPE management.
Failure to Administer Medications as Ordered Leads to Resident Agitation and Aggression
Penalty
Summary
The facility failed to administer medications as ordered for a resident, leading to increased agitation and aggressive behaviors. The resident, who had a history of severe mental illness and was admitted from a psychiatric hospital, did not receive prescribed doses of Trazodone and Quetiapine upon arrival at the facility. The Director of Nursing entered the medication orders into the electronic record, but due to a default in the software, the orders were set to start the following day. As a result, the resident did not receive the necessary medications on the day of admission, contributing to his agitation and aggressive behavior. The resident exhibited exit-seeking behavior and aggression, requiring multiple staff interventions. Despite having medications available in the facility's automated dispensing machines and in the resident's supply from the VA pharmacy, the medications were not administered as prescribed. Staff interviews revealed that medication aides did not always administer the medications due to unavailability or resident refusal, and they failed to document these occurrences or notify the nurses. This lack of communication and documentation contributed to the resident's behavioral escalation. The resident's aggressive behavior resulted in physical altercations with another resident and a staff member, leading to injuries. The facility's failure to administer medications as ordered and the lack of coordination and communication among staff members were significant factors in the events that transpired. The facility's policies on medication administration and emergency pharmacy services were not adequately followed, leading to the deficiency identified in the report.
Failure to Ensure Dignity and Proper Hygiene in Resident Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity while being provided care. Resident #14, who had a severely impaired cognitive status and required total dependence for mobility, transfers, dressing, toilet use, and personal hygiene, was observed being transferred into bed with a mechanical lift by two CNAs. During the care, one CNA placed the catheter bag on the bed at head level, causing the resident's face to be positioned directly on the catheter bag. Additionally, the CNA failed to cleanse the supra pubic catheter tubing and the stop valve tubing when emptying the catheter bag. The catheter bag was then placed on the bed frame, and a blanket was placed over the resident before the CNA left the room, indicating a lack of proper hygiene and dignity in care practices for Resident #14. Resident #14's diagnoses included cerebral palsy and obstructive uropathy, which necessitated careful and respectful handling during care procedures. The failure to follow proper protocols and maintain the resident's dignity during care was evident in this incident. Resident #21, who had a minimally impaired cognitive status and required assistance with mobility, transfers, dressing, toilet use, and personal hygiene, was frequently incontinent of bladder and always incontinent of bowel. Multiple observations revealed a strong odor of urine in Resident #21's room, with urine stains on the sheets and floor, and full urinals left on the floor. The housekeeping supervisor confirmed that the room had persistent odor issues due to residents spilling urinals and wet briefs being left in the room. This indicates a failure to maintain a clean and dignified environment for Resident #21, further compromising the resident's dignity and quality of care.
Failure to Maintain Odor-Free Environment
Penalty
Summary
The facility failed to ensure a clean and odor-free environment for Resident #21, who had a minimally impaired cognitive status and required varying levels of assistance with daily activities. Observations on multiple dates revealed a strong odor of urine in Resident #21's room, with specific instances of urine-stained sheets and full urinals left on the floor. The Housekeeping Supervisor confirmed that the room frequently had issues with odors due to residents spilling urinals and leaving wet briefs and pull-ups in the room.
Failure to Complete Wound Treatments as Ordered
Penalty
Summary
The facility failed to complete wound treatments in accordance with physician orders for two residents. Resident #15, who had a moderately impaired cognitive status and multiple diagnoses including Non-Alzheimer's dementia and respiratory failure, did not receive prescribed treatments for her face, scalp, wrist, and nostrils on multiple occasions. Specifically, treatments involving bacitracin, Vaseline, Sulfamylon, and Sodium Chloride Nasal Solution were either not transcribed on the Treatment Administration Record (TAR) or not administered as ordered on several dates in April and May 2024. This resulted in missed treatments on specific dates, including 4/25/24, 4/29/24, 4/30/24, and 5/1/24, among others. Similarly, Resident #12, who had an intact cognitive status but required significant assistance with daily activities and had multiple diagnoses including coronary artery disease and diabetes mellitus, did not receive prescribed treatments for an abrasion on his right inner thigh and for the application of Urea Cream 10% on his lower legs. The TAR indicated that these treatments were not provided on the evenings of 4/3, 4/21, and 4/27 for the abrasion, and on 4/3 and 4/21 for the Urea Cream. These omissions indicate a failure by the facility to adhere to physician orders and maintain professional standards of quality in wound care management for these residents.
Failure to Provide Adequate Personal Hygiene and Catheter Care
Penalty
Summary
The facility failed to ensure adequate personal hygiene services for three residents, including providing at least two bathing opportunities per week and proper catheter care. Resident #12, who had an intact cognitive status and required maximal assistance with daily activities, was not provided bathing opportunities as scheduled on two occasions and refused showers on two other occasions. The care plan for Resident #12 included specific instructions for bathing and skin inspection, which were not consistently followed. Resident #14, who had a severely impaired cognitive status and required total dependence for daily activities, was not provided bathing opportunities as scheduled on six occasions. Additionally, during observations, staff failed to properly cleanse the resident's suprapubic catheter tubing and stop valve, and placed the catheter bag in a position that allowed the resident's face to come into contact with it. The care plan for Resident #14 included specific instructions for bathing and catheter care, which were not consistently followed. Resident #18, who had an intact cognitive status and required moderate to maximal assistance with daily activities, was not provided bathing opportunities as scheduled on five occasions and refused showers on three other occasions. The care plan for Resident #18 included specific instructions for bathing and nail care, which were not consistently followed. The facility's catheter care policy outlined specific procedures for maintaining hygiene standards, which were not adhered to during the observed care of Resident #14.
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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