Pillar Of Cedar Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterloo, Iowa.
- Location
- 1410 West Dunkerton Road, Waterloo, Iowa 50703
- CMS Provider Number
- 165307
- Inspections on file
- 30
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Pillar Of Cedar Valley during CMS and state inspections, most recent first.
A resident with a history of mental illness repeatedly engaged in physical and verbal aggression toward other residents and staff, resulting in multiple altercations. Despite existing care plans and interventions, the facility did not consistently update documentation or adjust interventions after incidents, and staff interviews confirmed ongoing aggressive behaviors. The facility's failure to prevent and properly document these incidents led to emotional and physical distress among affected residents.
The facility did not report several incidents of physical aggression by a resident with mental health conditions toward other residents and staff to the state agency within the required timeframe. Although staff were trained and aware of reporting protocols, only one of multiple incidents was reported as required, and the care plan lacked clear direction for reporting and preventing further altercations.
A resident with a history of aggressive behaviors was involved in multiple altercations with other residents, but the facility did not thoroughly investigate the incidents or update care plans to include interventions to prevent recurrence. Required interviews and documentation were incomplete, and the facility's policy for investigating and reporting abuse was not consistently followed.
The facility failed to conduct a comprehensive assessment for Legionella growth in its water system and lacked a water management plan. Additionally, a resident with a PEG tube did not receive proper infection control measures, as an LPN handled the gastrostomy tube without gloves or PPE, despite Enhanced Barrier Precautions being in place. Staff interviews revealed a lack of communication and adherence to infection control policies.
The facility did not post notice of the availability of the most recent survey reports, nor were these reports readily accessible to residents, family members, and legal representatives. Observations showed a survey book placed on a rolling rack inside a community room, with no public display indicating its presence. Staff interviews revealed a lack of awareness about the requirement to post survey reports and their location.
A facility failed to maintain resident dignity and privacy, as observed in three cases. A resident with schizophrenia lacked a privacy curtain in his shared room, compromising his privacy. Another resident with anxiety disorder experienced a delay in assistance after activating her call light, despite being visibly uncomfortable. Additionally, a resident with schizophrenia and dysphagia received tube feeding in a common area against his wishes, affecting his dignity. These incidents highlight deficiencies in respecting resident rights and ensuring timely care.
A resident with COPD and respiratory failure was not consistently provided with oxygen therapy as ordered, receiving varying flow rates and at times no oxygen. Staff interviews revealed inconsistencies in following the physician's order for continuous oxygen at 2 liters per minute, and the facility lacked a policy on respiratory care.
A resident with a PEG tube for dysphagia was observed receiving enteral feeding in a dining room without proper infection control measures. An LPN administered the feeding without gloves or additional PPE, despite facility policy and an Enhanced Barrier Precautions sign indicating the need for such precautions. The resident required staff assistance for daily tasks and had a care plan to prevent infection at the gastrostomy tube site.
A resident with schizophrenia was found to have inadequate room space, measuring only 55 square feet instead of the required 80 square feet for shared rooms. The facility lacked a policy on room square footage, and the issue arose after adding bathrooms to rooms, reducing available space.
The facility failed to provide residents with direct access to an exit corridor from their designated room space, affecting four residents in a shared room. Two residents had to pass through others' spaces to exit, confirmed by the ADON and Maintenance Supervisor. The room's configuration changed after adding a bathroom, reducing space per resident. No policy on direct exit access was provided.
A facility failed to provide a privacy curtain between two residents, compromising the privacy of a resident with schizophrenia who was unable to make decisions about his own privacy. Staff acknowledged the absence of the curtain, which might have been removed for laundering or torn down by the other resident. The facility lacked a policy on privacy curtains.
A resident with intact cognition and multiple diagnoses was found without a call light in her room after moving to a new room. Observations and interviews confirmed the absence of the call light, and staff were unaware of the reason for its absence. Facility policy required call lights for residents changing rooms.
A resident with moderately impaired cognition and a history of falls reported an unwitnessed fall but did not receive a fall assessment or neurological checks as required by facility policy. Despite the resident's report and visible minor injury, staff failed to document the incident or conduct an investigation, contrary to the facility's fall prevention policy.
A resident with severe cognitive impairment and multiple diagnoses, including dementia and Parkinson's Disease, was left unattended in the shower room, leading to a fall. The care plan required staff assistance during bathing, but the resident was found on the floor without supervision. The DON acknowledged that the resident should not have been left alone.
Failure to Prevent and Document Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, resulting in multiple incidents involving physical and verbal aggression. One resident with a history of mental illness, including depression, anxiety, PTSD, and bipolar disorder, exhibited daily physical and verbal aggressive behaviors toward both staff and peers. Despite having care plans and interventions in place, such as behavior analysis, de-escalation techniques, and staff providing care in pairs, the resident continued to engage in aggressive acts, including hitting, yelling, and using inappropriate language toward other residents. Documentation revealed repeated altercations where this resident struck other residents in common areas, hallways, and during meal times, sometimes without provocation and sometimes following verbal exchanges. The facility's records showed that staff intervened by separating residents and redirecting the aggressive resident to her room, but these interventions did not prevent further incidents. There were also lapses in documentation, such as missing behavior charting and incident investigation summaries for some altercations. The care plans and individual program plans for the aggressive resident were not consistently updated following incidents, and there was a lack of timely evaluation and adjustment of interventions after repeated episodes of aggression. Staff interviews confirmed awareness of the resident's behaviors and the occurrence of multiple incidents involving physical aggression toward other residents and staff. Other residents involved in these incidents had diagnoses including anxiety, schizophrenia, and bipolar disorder, and some reported emotional distress following altercations. While some residents denied being afraid, they expressed concern about future incidents. The facility's policies required protection from abuse and outlined procedures for reporting and managing resident-to-resident altercations, but the repeated nature of the incidents and incomplete documentation indicated a failure to fully implement these protections and prevent abuse.
Failure to Timely Report Alleged Physical Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of physical abuse within the required timeframe to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for three out of four reviewed incidents. Clinical record review, facility records, policy review, and interviews revealed that incidents involving aggressive and physically abusive behaviors by a resident toward other residents and staff were not reported as mandated. The incidents occurred on multiple dates and included physical altercations such as hitting, striking, and other aggressive behaviors. One resident, with a history of mental illness including depression, anxiety, PTSD, and bipolar disorder, exhibited frequent physical and verbal aggression toward staff and peers. The resident's care plan identified these behaviors and included interventions for staff to manage and document such incidents. Despite these interventions, the care plan lacked specific direction for reporting resident-to-resident altercations and for implementing interventions to prevent further incidents after they occurred. Documentation showed that staff were aware of the reporting requirements and had received training on dependent adult abuse. However, the facility's self-reported incident list showed that only one of the four incidents was reported to DIAL, with the remaining three not reported as required. Interviews with staff and facility leadership confirmed that these incidents should have been reported, and facility policy required prompt reporting of such events to state authorities.
Failure to Investigate and Intervene After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and implement interventions following multiple resident-to-resident abuse incidents involving a resident with a history of aggressive behaviors. Clinical record review showed that this resident exhibited daily physical and verbal aggression, as well as daily rejection of care, and had diagnoses including depression, anxiety, PTSD, and bipolar disorder. Despite documented altercations with other residents on several occasions, the facility did not conduct comprehensive resident and staff interviews for the dates of the incidents to determine the extent of the allegations or whether other residents were affected. Additionally, the care plan lacked specific direction for staff to report and address resident-to-resident altercations after these incidents occurred. Facility documentation revealed that while some incidents were recorded and immediate actions such as separating residents and monitoring were taken, there was a lack of a complete investigation for at least one incident, and the care plan was not updated to include interventions to prevent further occurrences. The facility's policy required thorough investigation and reporting of all alleged violations, but this was not consistently followed, as evidenced by missing investigation summaries and incomplete follow-up after the incidents.
Deficiencies in Water Management and Infection Control Practices
Penalty
Summary
The facility failed to perform a comprehensive assessment to identify potential growth areas for Legionella and other opportunistic waterborne pathogens within its water system. Despite having a Legionella Policy, the Maintenance Supervisor admitted to not having a water mapping or management plan in place. The facility relied on the constant use of its water systems, such as showers and kitchens, to prevent stagnation, but did not conduct a formal assessment or develop a plan to monitor and prevent Legionella growth. The Administrator, who had experience with Legionella assessments, acknowledged the need for a water management plan, but no such plan was in place at the time of the survey. Additionally, the facility failed to implement proper infection control practices for a resident with a Percutaneous Enteral Gastrostomy (PEG) tube. The resident, who had a history of schizophrenia, dysphagia, and flaccid hemiplegia, required assistance with daily tasks and had an Enhanced Barrier Precautions sign posted on their door. However, an LPN was observed handling the resident's gastrostomy tube without wearing gloves or additional PPE, contrary to the facility's policy and the posted precautions. The LPN cleaned the g-tube port with an alcohol wipe and reattached the feeding tube in a communal dining area without following the required infection control measures. Interviews with facility staff revealed a lack of communication and understanding regarding the Enhanced Barrier Precautions and the necessary infection control practices. The Assistant Director of Nursing and the Director of Nursing both confirmed the expectation for staff to use appropriate PPE when handling gastrostomy tubes, but this was not adhered to in practice. The facility's failure to enforce its infection control policies and ensure staff compliance with Enhanced Barrier Precautions contributed to the deficiency in infection prevention and control.
Failure to Post and Make Survey Reports Accessible
Penalty
Summary
The facility failed to post notice of the availability of the most recent survey reports and did not have these reports readily accessible to residents, family members, and legal representatives. Observations on two consecutive days revealed that a three-ring binder labeled 'Department of Inspection and Appeals (DIA) Survey Book 1/6/22 to present' was placed flat on a rolling rack inside a set of double doors labeled as the community room. This area was a hallway leading to the facility conference room and the therapy room, and there was no public display or posting indicating that the facility survey results were available for review or where to find the survey book. Further observations showed that the binder remained in the same location, and no residents were seen accessing the area. Interviews with staff, including a scheduler and the Director of Nursing, revealed a lack of awareness regarding the requirement to post survey reports and their location. The Director of Nursing mentioned that the cart with the survey book had been moved due to recent repainting, but acknowledged that the facility had not posted information about the availability and location of the survey reports.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to uphold the dignity and privacy of its residents, as evidenced by several observations during an unannounced visit. Resident #29, who has schizophrenia and limited communication abilities, was found in a room without a privacy curtain separating his space from his roommate, Resident #64. This lack of privacy was acknowledged by the Assistant Director of Nursing and the Maintenance Supervisor, who were unaware of the reason for the missing curtain. Additionally, Resident #64 had to pass through Resident #29's space to enter or exit the room, further compromising privacy. Resident #27, diagnosed with anxiety disorder and schizoaffective disorder, experienced a delay in receiving assistance after activating her call light. Despite being visibly uncomfortable and sweating, she was left waiting for approximately 20 minutes before staff returned with the necessary equipment to assist her. The Director of Nursing later stated that call lights should be answered within 15 minutes, and staff should attempt to alleviate immediate discomfort even if they cannot fully meet the resident's needs immediately. Resident #52, who has schizophrenia, dysphagia, and flaccid hemiplegia, was observed receiving tube feeding in a common area, which was against his expressed wishes. The resident had been depressed since the placement of the gastrostomy tube and preferred to have feedings done in private. Despite this, a Licensed Practical Nurse connected the feeding tube in the dining room, exposing the resident's gastrostomy tube in front of others. The Director of Nursing acknowledged that this practice was a concern for resident dignity.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to adhere to the physician's order for continuous oxygen therapy at 2 liters per minute for a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Chronic Respiratory Failure with hypoxia. Observations revealed that the resident was receiving oxygen at varying flow rates, significantly higher than the prescribed 2 liters per minute, and at times, the resident was without oxygen therapy altogether. The resident was observed in the dining room with oxygen set at 6 liters per minute and later at 5 liters per minute while in bed. On another occasion, the resident was seen without oxygen in the dining room, while the oxygen concentrator in the room was running at 4.5 liters per minute. Interviews with staff indicated a lack of consistent adherence to the physician's order, with one LPN stating that the resident mainly wore oxygen when in bed and received it as needed in common areas. The Assistant Director of Nursing confirmed the order for continuous oxygen but noted that the resident sometimes refused to wear it outside the room. The Director of Nursing emphasized the expectation for staff to follow physician orders, yet the Facility Administrator admitted to not having a policy related to respiratory care or oxygen therapy, highlighting a gap in the facility's protocol management.
Infection Control Lapse During Enteral Feeding
Penalty
Summary
The facility failed to adhere to proper infection prevention protocols during the administration of enteral tube feeding for a resident. The resident, who had a Percutaneous Enteral Gastrostomy (PEG) tube due to dysphagia, was observed in the dining room without gloves or additional Personal Protective Equipment (PPE) being used by the staff member administering the feeding. The staff member, an LPN, cleaned the gastrostomy tube port with an alcohol wipe and attached the feeding tube without wearing gloves, despite the presence of an Enhanced Barrier Precautions sign on the resident's door indicating the need for additional PPE. The resident, who had diagnoses including schizophrenia, dysphagia, and flaccid hemiplegia, required staff assistance for daily tasks and had a care plan in place to prevent infection at the gastrostomy tube site. The facility's policy required staff to wash hands and don gloves before handling gastrostomy tubes to reduce infection risk. However, the LPN did not follow these protocols, and the Director of Nursing acknowledged the concern for resident dignity and the expectation for appropriate infection control practices.
Inadequate Room Space for Resident
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet of personal room space for residents with roommates, as evidenced by the case of a resident diagnosed with schizophrenia. This resident, who was rarely or never understood according to a Brief Interview for Mental Status, was observed to have a room space measuring only 82 inches by 98 inches, which is approximately 55 square feet. The resident's care plan indicated that he chose to sleep in a recliner and did not have a bed, which may have contributed to the oversight in room space allocation. The Maintenance Supervisor confirmed the inadequate room size and acknowledged that the room was previously certified for four residents. It was suggested that the addition of a bathroom to each resident's room might have reduced the available square footage per resident. The facility did not have a policy addressing the required square footage in resident rooms, which contributed to the deficiency. Discussions were underway to potentially move the resident to a different room to comply with space requirements.
Lack of Direct Exit Access for Residents
Penalty
Summary
The facility failed to ensure that residents had direct access to an exit corridor from their designated room space. This deficiency affected four residents who were residing in a room shared by four individuals. Specifically, two residents in the back of the room had to pass through the designated spaces of other residents to exit the room and access the hallway. Observations and interviews with the Assistant Director of Nursing and the Maintenance Supervisor confirmed that there was no direct way for these residents to enter or exit their allotted space without traversing through another resident's area. The Maintenance Supervisor acknowledged that the room was previously certified for four residents, but the addition of a bathroom to each room reduced the square footage per resident, contributing to the issue. The facility did not provide a policy regarding direct access to an exit corridor.
Lack of Privacy Curtain Between Residents
Penalty
Summary
The facility failed to provide a privacy curtain between two residents, resulting in a lack of privacy for one of the residents who was unable to make decisions regarding his own privacy. Observations revealed that there was no curtain between the designated room spaces of the two residents, despite a track being present on the ceiling for a curtain. The resident who was unable to respond had a diagnosis of schizophrenia and was rarely or never understood, indicating a need for privacy that he could not advocate for himself. Interviews with staff, including the Assistant Director of Nursing and the Maintenance Supervisor, confirmed the absence of the curtain and suggested it might have been removed for laundering or torn down by the other resident. The facility did not have a policy addressing privacy curtains, contributing to the oversight.
Deficiency in Call Light Availability for a Resident
Penalty
Summary
The facility failed to provide a working call light system for a resident, leading to a deficiency. The resident, who had intact cognition with a BIMS score of 13, was diagnosed with seizure disorder, benign paroxysmal vertigo, malnutrition, bipolar disorder, and schizophrenia. She moved to her current room on January 11, 2022, but was observed on September 30, 2024, and again on October 2, 2024, without a call light in her room. During interviews, the resident reported not having a call light and was unaware that all rooms should have one. Staff members, including a Licensed Practical Nurse and the Assistant Director of Nursing, confirmed that the resident should have a call light but were unsure why it was missing or how long it had been absent. The facility's policy, dated January 1, 2019, stated that staff should ensure residents who change rooms have a call light available.
Failure to Conduct Fall Assessment for Self-Reported Fall
Penalty
Summary
The facility failed to complete a fall assessment or neurological checks following a resident's self-reported, unwitnessed fall. Resident #53, who has moderately impaired cognition and a history of falls, reported falling in her room but could not recall the details. Despite this report, there was no fall incident report or assessment documented in the resident's records. The resident was found crawling on the floor and later reported to staff that she had fallen, but no immediate assessment or investigation was conducted by the nursing staff. The facility's policy requires an investigation into the circumstances of a fall, completion of a fall assessment, and documentation in the electronic health record. However, these steps were not followed after Resident #53's report. Staff members, including a CNA and the ADON, were informed of the fall but did not perform the necessary assessments or complete an incident report. The DON confirmed that the expectation is for nursing staff to assess any resident who reports a fall, whether witnessed or not, and to complete the necessary documentation and assessments.
Resident Left Unattended in Shower Room Resulting in Fall
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident #79, who was left unattended in the shower room, resulting in a fall. The resident, who had severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 03, was diagnosed with hypertension, dementia, Parkinson's Disease, anxiety, and depression. The care plan for the resident, revised on 9/26/24, specified that the resident required assistance from one staff member during bathing. However, on 7/19/24, a nursing progress note documented that the resident was found on the floor in the shower room without any staff supervision, although no injuries were noted. The Director of Nursing confirmed that the resident should not have been left unattended in the shower.
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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