Pioneer Valley Living And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Sergeant Bluff, Iowa.
- Location
- 400 Sergeant Square Drive, Sergeant Bluff, Iowa 51054
- CMS Provider Number
- 165615
- Inspections on file
- 25
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Pioneer Valley Living And Rehab during CMS and state inspections, most recent first.
Food was not consistently served at an appetizing temperature for 3 residents. Two residents with intact cognition reported that meals delivered to their rooms were often cold or only room temperature, and another resident said meals were cold most of the time. Surveyors also checked trays and found hot items and vegetables at low temperatures, while the Dietary Manager acknowledged that trays traveled down the hallways for delivery and that food temperatures should be appropriate.
A resident with heart failure, diabetes mellitus, and HTN had a physician order for daily weights with PRN Bumetanide and instructions to notify the physician for specified weight gains. Over multiple months, MAR review showed numerous instances where the daily weights were refused or marked as not applicable, yet the clinical record contained no documentation that the physician was notified of these refusals or missed weights. The ADON acknowledged there was no documentation of such notification, and the facility did not have a policy addressing when to notify the physician in these situations.
Incomplete ABN Forms for Skilled Services: The facility failed to properly complete CMS form 10055 for 3 residents. The ABNs were missing required information such as the reason Medicare may not pay and/or the estimated cost of skilled nursing care. The Administrator stated that the approximate cost of services is required on the form and noted that other forms had been completed correctly.
Failure to update PASARR after new delusional disorder diagnosis. A resident with anemia, HF, agitation/restlessness, and moderate cognitive impairment had a negative Level I PASARR, then later had a physician-documented dx of delusional disorder while receiving olanzapine. The chart showed the dx was added to the medical record and MAR, but the PASARR did not include the new dx and no updated PASARR was in the record.
A resident with HF, DM, HTN, and a BIMS of 15 was started on hospice for pain control, but the care plan was not updated to include hospice services or the chosen hospice agency. Progress notes showed the POA requested hospice, hospice evaluated the resident, orders were obtained, and the resident remained on hospice, yet the revised care plan still lacked this information.
Failure to monitor and document a coccyx pressure area led to a deficiency for a resident with Alzheimer’s disease, DM, HTN, and severe cognitive impairment. Skin checks were missed or lacked documentation, the physician was not timely notified of the new open area, and the record showed no documented treatment for the wound for a period of time. The resident later had an ongoing coccyx pressure ulcer with orders for wound care and nutritional support.
The facility did not carry out the required number of weekly audits as outlined in its QAPI Plan of Correction, resulting in repeated deficiencies in areas such as professional standards, quality of care, and infection control. The administrator cited a misunderstanding about audit requirements, and oversight responsibilities were not met according to the facility's QAPI plan.
A resident with a history of hemiplegia, depression, and muscular dystrophy, who was dependent on staff for toileting, was left waiting in the dining room in soiled garments for about 30 minutes after an incontinence episode because staff were occupied feeding other residents. Staff and DON interviews confirmed that assistance should have been provided, and facility policy requires residents to be treated with dignity.
A resident with severe cognitive impairment, total dependence for care, and recent admission to Hospice experienced a significant decline in condition. Despite this, the facility did not complete a Significant Change MDS assessment within the required timeframe after recognizing the change, as confirmed by record review and staff interview.
The facility did not submit comprehensive MDS assessments within the required timeframe for two residents. In both cases, the assessments were completed and accepted late, and staff interviewed were unable to provide a response regarding the delay. Facility policy requires timely initiation, encoding, and transmission of assessments per CMS RAI guidelines.
The facility did not update or individualize care plans for several residents with complex medical needs, including those with skin breakdown, edema, pressure ulcers, and use of pressure-relieving devices. Care plans lacked specific interventions for conditions such as edema, skin wounds, and the use of Prafo boots, despite physician orders and direct observations. Additionally, one resident's care plan contained outdated target dates, showing a lack of regular review by the interdisciplinary team.
The facility did not follow physician orders for two residents, including administering medication despite blood pressure parameters and failing to obtain daily weights or notify the physician after a significant weight gain. The affected residents had complex medical histories, including diabetes, hypertension, and heart disease.
A resident with severe cognitive impairment and total dependence on staff for mobility and toileting did not consistently receive restorative services as outlined in their care plan. Documentation showed that exercise opportunities were frequently missed or marked as not applicable, and staff interviews revealed a lack of training, unclear responsibilities, and staffing shortages. The facility did not have a policy on restorative services, contributing to the deficiency.
A resident with advanced dementia and mobility deficits was not repositioned for over five hours while seated in a Broda Reclining wheelchair, despite being at risk for skin impairment and having a documented pressure area. Multiple staff passed by without providing repositioning or checking personal needs, and staff interviews revealed inconsistent understanding of repositioning requirements.
Two residents experienced inadequate monitoring and intervention for skin issues, including inconsistent wound care application and incomplete documentation of skin assessments. One resident with multiple comorbidities and skin breakdown did not have detailed wound measurements or consistent dressing changes, while another at risk for pressure ulcers did not receive weekly skin assessments as ordered. Facility policies and physician orders for individualized skin care and documentation were not followed.
A resident with severe cognitive impairment and a right heel pressure ulcer was repeatedly observed without the required protective boots and prescribed dressing, despite orders for their continuous use. Staff did not consistently communicate or address the absence of the dressing, and the facility's pressure ulcer prevention protocols were not followed, resulting in inadequate care for the resident.
A resident with moderate cognitive impairment and mobility deficits was observed being pushed in a wheelchair without foot rests by a CNA, contrary to facility policy and staff expectations. Multiple staff interviews confirmed that foot rests are required when transporting residents in wheelchairs, but this protocol was not followed.
Staff did not follow Enhanced Barrier Precautions when providing wound care to a resident with a stage 2 pressure injury, as they failed to wear gowns and did not have appropriate PPE signage posted. The resident was dependent on staff for care and had a care plan indicating skin integrity issues, but EBP protocols were not followed during a dressing change.
A resident at moderate risk for pressure ulcers was repeatedly left sitting in a recliner without a pressure-reducing cushion, despite documented care needs and staff awareness of his inability to reposition himself. The care plan lacked interventions for skin integrity, and staff did not consistently communicate or implement preventive measures, resulting in the development of two open sores on the resident's buttocks.
A resident with diabetes received both long-acting and short-acting insulin from an LPN despite a blood sugar reading below the physician-ordered threshold for notification. The LPN did not contact the physician as required, and the resident was later found unresponsive with severe hypoglycemia, requiring emergency intervention and hospitalization.
Two residents experienced injuries during mechanical lift transfers due to staff failing to follow facility policy and manufacturer guidelines, including using only one staff member for transfers that required two and not ensuring proper use of equipment, resulting in a fractured thumb and a fall.
The facility experienced repeated deficiencies in its QAPI program, including failures in comprehensive assessments, care planning, and infection control. Despite having a QAPI plan and recent performance improvement initiatives for MDS and falls, ongoing staff turnover and reliance on third-party management contributed to the recurrence of these issues.
The facility did not complete or submit required MDS assessments for four residents, including discharge, End of PPS Part A Stay, admission, and death in facility assessments. These failures were confirmed through record review and staff interviews, with the administrator acknowledging that MDS assessments had not been consistently completed.
The facility did not develop or maintain comprehensive care plans for several residents with specialized needs, including those requiring CPAP, catheter care, fall interventions, and hospice services. Observations and staff interviews revealed missing or inaccurately documented care plans, with staff acknowledging gaps in training and documentation practices.
The facility did not develop or update individualized care plans for four residents, resulting in missing interventions for skin integrity, transfer assistance, behavioral management, and use of mechanical lifts. For example, a resident with a history of pressure injuries lacked a care plan for skin protection, another experienced a fall during a transfer not addressed in the care plan, and two residents on psychotropic medications or with behavioral symptoms had incomplete care plans lacking necessary interventions and monitoring.
The facility did not consistently monitor for expired medications or document open dates on insulin pens for multiple residents. Staff relied on general rules for medication expiration and did not verify medication details during shift changes, leading to expired hydrocodone and insulin pens without open dates remaining in use. Facility policy required documentation of open dates and prompt removal of expired medications, but these procedures were not followed.
Surveyors found that required comprehensive MDS assessments were not completed in a timely manner for three residents. In each case, either annual or admission assessments were left incomplete or still in progress, with the administrator citing staff shortages and unclear assignment of responsibilities as contributing factors.
A resident with multiple diagnoses was readmitted from the hospital and admitted to hospice care, but the facility did not complete the required significant change MDS assessment within 14 days of recognizing the change in condition. The assessment was completed 23 days after hospice admission, and the care plan lacked documentation about the hospice provider and services.
Quarterly MDS assessments were not completed within the required timeframe for three residents, with assessments either delayed by several months or not completed at all. The Administrator confirmed that changes in leadership and MDS staffing contributed to the failure to meet CMS requirements for timely resident assessments.
A resident's MDS assessment inaccurately documented the presence of a stage 2 pressure ulcer, despite staff interviews confirming the resident did not have a pressure ulcer but instead had a laceration. The facility also did not have a policy for maintaining accurate resident records.
Three residents with varying medical and cognitive conditions were admitted without receiving a written summary of their baseline care plan, and there was no documentation that staff reviewed the initial care plan with the residents or their representatives. Facility staff used a kardex as the baseline care plan but did not provide it to residents or families, nor retain the original version, resulting in missing required documentation.
A resident with COPD and respiratory failure, dependent on supplemental oxygen, was repeatedly observed wearing oxygen tubing that was not labeled with a date of application. Staff provided inconsistent information about the frequency of tubing changes, and facility records lacked orders or documentation for this care. No facility policy was provided regarding the changing and documentation of oxygen tubing.
Staff failed to follow infection control protocols for two residents with medical devices. An LPN administered tube feeding and medications without wearing a gown and stepped on oxygen tubing, while another resident's urinary catheter bag was found on the floor without a privacy cover. The DON confirmed these were breaches of infection prevention standards.
A resident with multiple chronic conditions and no cognitive impairment reported that a CNA used excessive force while cleaning her face and eyes, causing pain and bruising, and did not stop when asked. The incident was corroborated by nursing and social work staff, who observed the bruising and documented the resident's complaint. The resident described the staff member involved, and the DON confirmed the resident's reliability and the facility's expectation for gentle care.
Staff did not follow physician orders for two residents, including failing to notify the provider of repeated high blood pressure readings for one resident and not documenting non-pharmacological interventions before administering PRN anti-anxiety medication to another. Nursing staff and the DON confirmed that required documentation and interventions were not consistently completed.
Three residents did not receive appropriate care due to missed neurological assessments after a fall, delayed hospital transfer, and repeated missed medication doses because medications were not available. In addition, there was a lack of physician notification regarding missed medications and failure to document or follow family wishes about a resident's medication regimen.
The facility did not maintain accurate records for two residents, including missing documentation of required weekly weights for a resident with a feeding tube and lack of evidence that a provider was contacted after repeated high blood pressure readings for another resident, despite MAR entries indicating otherwise.
Food Served at Inappropriate Temperatures
Penalty
Summary
Food and drink were not consistently provided at an appetizing temperature for 3 of 5 residents reviewed, including Residents #8, #32, and #35. Resident #8, whose MDS showed a BIMS score of 15, stated that she often eats in her room and that meals are often cold when delivered because they sit longer before reaching her. Resident #32, whose MDS also showed a BIMS score of 15, reported that she prefers to eat in her room and is lucky if meals are even room temperature, adding that several meals have been delivered cold. Survey observations confirmed low food temperatures on tray checks. One tray included a hot ham and cheese sandwich at 109.2 degrees, green beans at 125.2 degrees, french fries at 101.1 degrees, and mandarin oranges at 46.8 degrees; another tray showed caramelized butternut squash at 118.4 degrees and mixed vegetables at 120.9 degrees. The Dietary Manager acknowledged that the trays went down the hallways for delivery and stated that food temperatures should be served at the appropriate temperatures. Resident #35, whose MDS showed a BIMS score of 15, reported that the food is cold most of the time and stated that, when asked about meals, it was cold like most of the time and most days, most meals.
Failure to Notify Physician of Repeated Refusal of Ordered Daily Weights
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to notify the physician when a resident repeatedly refused ordered daily weights or when weights were not completed. The resident had diagnoses of heart failure, diabetes mellitus, and hypertension, and an MDS assessment documented a BIMS score of 15, indicating no cognitive impairment. A physician-signed order dated 1/29/26 required daily weights, with PRN Bumetanide and instructions to notify the physician for specified weight gains. Review of the January, February, and March 2026 Medication Administration Records showed multiple days where daily weights were either refused or marked as not applicable, including numerous refusals across all three months. Despite these repeated refusals and missed weights, review of the clinical record showed no documentation that the physician had been notified about the resident’s refusal of daily weights or the failure to complete them. The facility also lacked a policy addressing physician notification in such circumstances. During an interview, the ADON confirmed there was no documentation of physician notification regarding the resident’s refusal of daily weights or incomplete weights, although the ADON stated an expectation that staff notify the physician when orders are not being completed.
Incomplete ABN Forms for Skilled Services
Penalty
Summary
The facility failed to properly complete CMS form 10055, the Skilled Nursing Facility Advanced Beneficiary Notice, for 3 of 3 sampled residents: Resident #4, Resident #8, and Resident #54. The census was 48 residents. For Resident #4, the ABN dated 1/26/26 lacked the reason Medicare may not pay and the estimated cost of services. For Resident #8, the ABN dated 8/5/25 lacked the estimated cost of skilled nursing care. For Resident #54, the ABN dated 10/2/25 also lacked the estimated cost of skilled nursing care. The facility’s Medicare Advanced Beneficiary Notice policy dated April 2021 stated that if the admissions coordinator or business office manager believes Medicare will not pay for otherwise covered skilled services, the resident or representative is to be notified in writing why the services may not be covered and of the resident’s potential liability for payment of the non-covered service(s). The CMS beneficiary notice instructions cited in the report stated that notifiers must complete the cost estimate column and make a good faith effort to insert a reasonable estimate for the items or services listed. In an interview on 2/25/25 at 2:54 PM, the Administrator stated that the approximate cost of services is required to be completed on ABN form 10055 and said, "I have reviewed other forms, and it's filled out. I don't know how those were missed."
Failure to Update PASARR After New Delusional Disorder Diagnosis
Penalty
Summary
The facility failed to refer one resident with a negative Level I PASARR result for a Level II PASARR evaluation after the resident was later identified with a newly evident or possible serious mental disorder. Resident #14’s MDS assessment documented anemia, heart failure, agitation and restlessness, and a BIMS score of 12 indicating moderate cognitive impairment. The clinical record also showed a pharmacy communication dated 2/17/26 asking for the diagnosis that best fit the resident’s use of antipsychotic medication, olanzapine 5 mg daily, with the physician marking delusional disorder and signing the response on 2/20/26. A DON progress note dated 2/23/26 stated that the signed pharmacy communication was received, the physician responded with F22 Delusional Disorder, and the diagnosis list, MAR, and chart were updated. Review of the current medical diagnoses showed delusional disorder with a created date of 2/23/26, but the PASARR dated 1/30/26 did not include delusional disorder, and the clinical record lacked an updated PASARR to reflect that diagnosis. The facility also did not have a policy on PASARR procedures, and the DON stated in interview that the diagnosis should be listed on the PASARR and that she would submit a new one.
Care Plan Not Updated to Include Hospice Services
Penalty
Summary
The facility failed to revise and update the care plan to include hospice care for one resident reviewed. The resident’s MDS assessment documented diagnoses of heart failure, diabetes mellitus, and hypertension, and the BIMS score was 15, indicating no cognitive impairment. The resident later stated that hospice had recently been started to help with pain control. Progress notes showed that the resident’s POA requested a hospice consult, chose a hospice agency, and hospice visited the resident and contacted the primary care physician for orders. A verbal order was obtained for hospice to evaluate and treat if appropriate, and a signed order was later received and filed in the chart. Subsequent progress notes documented that the resident remained on hospice, but the care plan revised on 2/25/26 did not include hospice services or the hospice care choice. The DON stated hospice care should be listed on the face sheet and on the care plan, and the MDS coordinator stated the hospice information normally would have been entered but was missed.
Failure to Monitor and Document Coccyx Pressure Area
Penalty
Summary
The facility failed to complete skin assessments and failed to notify the physician in a timely manner regarding a new pressure area to the coccyx for Resident #3, a resident with Alzheimer’s disease, diabetes mellitus, hypertension, and a BIMS score of 3 indicating severe cognitive impairment. The resident’s MDS identified pressure ulcer staging definitions, and the care plan included interventions for a stage 2 pressure ulcer to the coccyx, pressure reduction measures, incontinence care, skin monitoring, and treatment per physician order. Braden Scale assessments showed the resident was at moderate risk for pressure sores on multiple dates. Progress notes documented a small open area to the base of the tailbone on 12/30/25, with cream applied and the doctor notified. However, the clinical record lacked documentation of any treatment of the open area from 12/30/25 through 1/19/26. The weekly skin observation tool also lacked documentation on 12/25/25 and 1/8/26, and later entries documented redness, a small open area, and ongoing open areas to the coccyx with varying measurements. A physician order dated 1/19/26 directed application of house camo every shift and as needed until healed, and a later order dated 2/13/26 added 2 Cal 80 cc three times daily to promote wound healing and address poor intake. The TAR for January 2026 showed the wound treatment order beginning on 1/19/26, but the record did not document treatment of the coccyx area between 12/30/25 and 1/19/26. On 3/3/26, observation revealed an open area to the resident’s coccyx. Facility policy titled Pressure Injury Surveillance stated that a system of surveillance is used for preventing, identifying, reporting, and investigating new or worsened pressure injuries, and that all pressure injuries will be tracked. During interview, the DON stated the skin sheets should have been completed, that they were being audited by the prior ADON, and that she should have been aware they were not completed and should have known about the area. The DON also stated there was no documentation between 12/30/25 and 1/19/26 with the physician regarding the wound or treatments being completed during that time.
Failure to Implement Effective QAPI Program and Audit Processes
Penalty
Summary
The facility failed to implement a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program as required. Repeated deficiencies were identified during annual surveys and complaint investigations, including issues related to services meeting professional standards, quality of care, QAPI program and plan, and infection prevention and control. The facility's Plan of Correction (POC) specified that four files per week would be audited for several areas, but only two files per week were actually audited over multiple weeks, falling short of the stated plan. The administrator acknowledged a misunderstanding regarding the number of files to be audited weekly, which contributed to the failure to meet the POC requirements. The QAPI Facility Plan indicated that the governing body or facility administration was responsible for oversight of QAPI activities, including identifying and prioritizing problems based on performance data and input from residents and staff. However, the facility did not follow through with the planned audits, resulting in noncompliance with QAPI program requirements.
Resident Left in Soiled Garments Due to Delayed Assistance
Penalty
Summary
A deficiency occurred when a resident with normal cognitive function and a history of hemiplegia, depression, and muscular dystrophy was left waiting in the dining room in soiled garments after experiencing an incontinence episode. The resident, who was dependent on staff for toileting and transfers, reported that staff told her she could not be taken back to her room to be changed because they were feeding other residents. The resident stated she waited approximately 30 minutes before being assisted back to her room for care. Staff interviews confirmed that during meal times, most CNAs assist in the dining room, with only one or two available to respond to other needs, such as toileting assistance. The DON stated that staff are expected to assist residents requesting to return to their rooms due to incontinence. Facility policy also affirms residents' rights to adequate care and dignity. The failure to promptly assist the resident resulted in her remaining in soiled garments, which did not honor her right to dignity.
Failure to Complete Significant Change MDS After Resident's Decline and Hospice Admission
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (SCMDS) within 14 days after recognizing a significant change in condition for a resident. The resident, who had a severe cognitive deficit as indicated by a BIMS score of 0, was totally dependent on staff for toileting and transfers, and was admitted to Hospice care. Documentation showed that the resident was admitted to Hospice services on January 25, and the care plan was updated to reflect a decline in cognition and physical condition. However, the electronic chart only showed quarterly MDS assessments and lacked a SCMDS following the significant change. The facility administrator acknowledged the omission during an interview.
Failure to Submit MDS Assessments Within Required Timeframe
Penalty
Summary
The facility failed to submit comprehensive Minimum Data Set (MDS) assessments within the required timeframe as directed by the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual for two out of fifteen residents reviewed. Specifically, one resident's quarterly MDS assessment was accepted several days after the assessment date, and another resident's quarterly MDS assessment was completed and accepted well over a month after the assessment date. During interviews, the Director of Nursing and another staff member stated they did not have a response regarding the completion and submission of the MDS documents, as they were not responsible for completing them. Facility policy requires that assessments be initiated, encoded, and transmitted according to CMS RAI guidelines.
Failure to Update and Individualize Resident Care Plans
Penalty
Summary
The facility failed to update and provide individualized care plans for three residents with long-standing conditions. For one resident with moderate cognitive impairment, diabetes, chronic kidney disease, edema, and diabetic neuropathy, the care plan did not include focus areas or interventions for edema or skin breakdown, despite observations of significant swelling, fluid-filled blisters, and open sores on the lower extremities. The resident was dependent on staff for multiple activities of daily living and was being seen by an outside wound clinic, but these specific skin and edema issues were not addressed in the care plan. Another resident with advanced dementia, decreased mobility, and incontinence was at risk for pressure ulcers and had a documented pressure area on the right inner ankle. The care plan identified a general risk for skin impairment and included some interventions, but it was not updated to reflect the specific treatment for the ankle wound or the use of Prafo boots when out of bed, as observed and ordered by the physician. Multiple observations confirmed the resident was consistently wearing Prafo boots both in bed and out of bed, but this was not documented in the care plan. A third resident with a history of stroke, hemiplegia, and depression, who was at risk for pressure ulcers and had a diabetic foot ulcer, also had a care plan that did not include the use of Prafo boots for pressure avoidance, despite physician orders and repeated observations of the resident wearing them. Additionally, another resident's care plan contained outdated target dates for all focus areas, indicating a lack of regular review and updating as required by facility policy.
Failure to Follow Physician Orders for Blood Pressure and Weight Monitoring
Penalty
Summary
The facility failed to follow physician's orders and professional standards of quality for two residents. For one resident with a history of bariatric surgery, diabetes, chronic kidney disease, and adult failure to thrive, staff did not adhere to the medication order for Midodrine, which specified to hold the medication if the systolic blood pressure was over 100. Despite this, the medication was administered multiple times when the resident's systolic blood pressure readings were above the specified threshold. Additionally, the resident was observed with supplemental oxygen tubing not in use as intended, and she reported sometimes forgetting to put it back on. For another resident with hypertension, diabetes, morbid obesity, edema, and heart disease, the facility failed to obtain daily weights as ordered and did not notify the physician when the resident experienced a significant weight gain of 13 pounds in one day. The care plan required daily weights and physician notification for specific weight changes, but documentation showed missed weight recordings and no evidence of physician notification after the rapid weight gain. The facility also lacked policies on edema or blood pressure management.
Failure to Implement Restorative Services for Dependent Resident
Penalty
Summary
The facility failed to implement restorative services for a resident with severe cognitive impairment, who was totally dependent on staff for toileting and transfers, and required substantial assistance with dressing. The resident also had a stage 2 pressure injury and was receiving hospice care. The care plan indicated the need for a program to maintain strength and mobility, including daily use of exercise equipment and range of motion (ROM) exercises as tolerated. However, documentation showed that out of 52 opportunities to assist the resident with exercises over a 26-day period, staff marked half as not applicable, several as refused, and only a few as completed. Interviews with staff revealed a lack of training and clear assignment regarding restorative services. The Director of Rehabilitation confirmed that staff were not trained on restorative services or ROM exercises. Multiple staff members, including CNAs and LPNs, indicated that restorative services were inconsistently provided due to staffing shortages and lack of designated personnel. The Director of Nursing stated that CNAs were expected to offer restorative exercises but there was no special person assigned, and one CNA was unaware of the restorative program. The facility administrator acknowledged the program was not functioning as it should and confirmed the absence of a policy on restorative services.
Failure to Reposition Resident Leading to Prolonged Immobility
Penalty
Summary
Staff failed to reposition a resident with advanced dementia, decreased mobility, and incontinence for over five hours while the resident was seated in a Broda Reclining wheelchair. The resident, who was at risk for skin impairment and had a documented pressure area on the right inner ankle, was observed in the same position from 7:55 AM until 1:22 PM, with only brief movement to and from the dining room. During this period, multiple staff members passed by without repositioning or checking on the resident’s needs, despite the care plan indicating the need for frequent repositioning and the use of pressure-relieving devices. Interviews with staff revealed inconsistent understanding of repositioning requirements, with some staff believing that adjusting the wheelchair’s recline constituted repositioning, while others stated that residents should be laid down or rolled to prevent pressure sores. The facility’s policies referenced frequent repositioning but did not specify the required frequency. The lack of consistent repositioning and unclear policy guidance contributed to the failure to provide necessary care and assistance with activities of daily living for the resident.
Failure to Monitor and Document Skin Issues and Wound Care
Penalty
Summary
The facility failed to adequately monitor and intervene for skin issues in two residents, resulting in deficiencies in wound care and documentation. One resident with a moderate cognitive deficit, multiple comorbidities including diabetes and chronic kidney disease, and a history of moisture-associated skin damage, was dependent on staff for most activities of daily living. The care plan for this resident lacked specific interventions for skin breakdown and edema, despite ongoing issues with fluid retention and visible swelling. Observations revealed that wound treatments were inconsistently applied, with missing or undated dressings, and the resident sometimes had to remind staff to perform wound care. Documentation in the clinical record and on weekly skin assessment tools was incomplete, lacking detailed descriptions and measurements of wounds, and did not consistently reflect the resident's current condition, including new blisters and changes in skin integrity. Another resident, who had normal cognition but was at risk for pressure ulcers due to a history of stroke and hemiplegia, also experienced lapses in required skin monitoring. The care plan identified the resident as being at moderate risk for pressure ulcers and included interventions such as pressure-relieving devices. However, the facility failed to complete the required weekly skin observation tool as ordered by the physician, with the last assessment being overdue by 14 days at the time of review. This omission was confirmed by the Director of Nursing, who was unable to provide an explanation for the missed assessments. Facility policies required individualized assessment and care planning for residents at risk of skin breakdown, including weekly measurement and documentation of ulcers and prompt notification of physicians regarding new skin issues. Despite these policies and specific physician orders, the facility did not ensure that wound care treatments and assessments were consistently implemented or documented for the affected residents.
Failure to Provide Consistent Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide appropriate interventions for pressure ulcer prevention and care for one resident with a known pressure ulcer on the right heel. The resident, who had severe cognitive impairment and was dependent on staff for mobility and personal care, was observed multiple times without the ordered protective boots and without the prescribed dressing on the affected heel. Documentation showed that the resident's wound progressed from a Stage II to a Stage IV ulcer, and treatment orders required the use of a protective boot at all times and regular dressing changes. Despite these orders, the resident was seen in public areas without the protective boots and was later found without a treatment dressing during a transfer for bathing. Staff interviews confirmed that the absence of the dressing was noticed only during care activities, and there was a lack of consistent communication to ensure prompt replacement of the dressing. The facility's policy required staff to implement pressure relief measures and maintain appropriate positioning and protective surfaces, but these measures were not consistently followed. The resident's care plan and treatment orders were not adhered to, resulting in lapses in pressure ulcer prevention and care.
Resident Pushed in Wheelchair Without Foot Rests
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, non-Alzheimer's dementia, and depression was observed being pushed in a manual wheelchair without foot rests by staff. The resident required partial to moderate assistance for transfers and ambulation, as documented in the Minimum Data Set and care plan. Observations showed the resident self-propelling the wheelchair with feet slightly off the floor and later being pushed by a CNA for a distance of at least 50 feet without foot pedals attached. Multiple staff members, including CNAs, a physical therapist assistant, and the Director of Nursing, confirmed during interviews that facility policy requires foot rests to be in place and residents' feet to be on the foot rests when being pushed in a wheelchair. The facility's own policy also specifies that foot rests must be lowered and the resident's feet placed on them prior to transport. Despite these requirements, the resident was transported without foot rests, constituting a failure to protect the resident from potential accident hazards.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) during wound care for a resident with a stage 2 pressure injury. The resident, who had severe cognitive impairment, was totally dependent on staff for toileting and transfers, and required substantial assistance with dressing. The resident was also on hospice care and had a care plan indicating skin integrity impairment and the need for protective boots. During a wound dressing change to the resident's right foot, three staff members, including a registered nurse and two certified nurse aides, did not wear gowns as required by EBP protocols. Additionally, there was no EBP signage posted on the resident's door to alert staff to the need for full personal protective equipment (PPE) during high-contact care activities. The facility's policy required the use of gowns and gloves for residents with wounds or indwelling medical devices, but this was not followed in the case of the resident with an open wound. The administrator acknowledged the failure to implement EBP during care.
Failure to Provide Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement appropriate interventions to prevent pressure ulcers for a resident who was at moderate risk for skin breakdown. Despite care plan instructions and MDS documentation indicating the need for pressure-reducing devices in both the chair and bed, the resident was repeatedly observed sitting in a recliner for extended periods without any pressure-reducing cushion. Staff interviews and observations confirmed that the resident was unable to shift his weight independently and often waited long periods for assistance, with staff acknowledging the absence of protective padding and the need for such devices. The resident, who had a history of renal insufficiency, peripheral vascular disease, hip fracture, and significant weight loss, developed two open sores on his buttocks. Documentation showed that the care plan lacked any reference to skin conditions or interventions for pressure sore prevention, despite the resident's declining mobility, increased weakness, and previous episodes of skin breakdown. Staff did not consistently apply prescribed creams, and communication lapses were noted between CNAs and licensed nurses regarding new or worsening skin issues. Multiple observations over several days revealed the resident sitting in soiled briefs and on unprotected recliner seats, with staff only intermittently providing absorbent padding and not pressure-reducing cushions. The facility's own assessment indicated a high percentage of residents at risk for skin breakdown, yet individualized preventive measures were not implemented for this resident. The facility's policy required assessment and care planning to prevent pressure sores, but these were not followed in this case.
Failure to Prevent Significant Medication Error in Insulin Administration
Penalty
Summary
A resident with diagnoses of diabetes mellitus, renal insufficiency, and hypertension required insulin injections for diabetes management and had physician orders for blood sugar checks four times daily, with instructions to notify the physician if blood sugar was less than 70 mg/dl or greater than 250 mg/dl. On the morning in question, the resident's blood sugar was recorded at 69 mg/dl, which was below the threshold requiring physician notification. Despite this, the LPN administered both long-acting and short-acting insulin as scheduled, without contacting the physician as required by the order. Following the administration of insulin, the resident was found unresponsive but breathing, with a blood sugar of 34 mg/dl. The nurse administered glucagon and called emergency services, resulting in the resident being transported to the emergency room. The ER record confirmed the resident was treated for hypoglycemia and subsequently admitted for other medical issues. The nurse later acknowledged that the short-acting insulin likely contributed to the further drop in blood sugar and that the physician should have been contacted before administering insulin when the blood sugar was below the specified threshold. The facility's blood glucose monitoring policy did not provide specific direction for diabetes treatment, and only the involved nurse received counseling and education following the incident. The deficiency was identified due to the failure to follow physician orders regarding insulin administration and blood sugar monitoring, resulting in a significant medication error and the resident's hospitalization.
Failure to Prevent Accidents During Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents during transfers for two of three residents reviewed. One resident with mild cognitive impairment, Parkinson's disease, and total dependence on two staff for transfers with a mechanical lift was transferred by a single staff member using an EZ stand, contrary to facility policy and the resident's care plan. This resulted in the resident sustaining a fractured right thumb, which was discovered the following morning when the resident was unable to release his hands for a pulse oximeter reading. The staff member responsible for the transfer did not report the incident or injury to the nurse or the oncoming shift, and multiple staff interviews confirmed that mechanical lifts were often used with only one staff member due to staffing shortages or busy shifts, despite the policy requiring two staff for such transfers. Another resident, who had intact cognitive functioning but was experiencing weakness and illness, required partial assistance for transfers and used a walker and wheelchair for mobility. During an episode of increased weakness, two CNAs attempted to transfer the resident to the bathroom using a Sit to Stand (STS) mechanical lift. The resident was unable to support her own weight and slid out of the sling onto the floor. Staff interviews revealed that the resident was not standing well on the machine, her arms were not properly positioned, and there was uncertainty about whether the sling's belt was tightened as required by the manufacturer's instructions. The incident occurred after the nurse instructed staff to use the STS due to the resident's inability to transfer as usual, and the resident was later found to have been septic with a urinary tract infection. Documentation and staff statements indicated a pattern of non-compliance with facility policy and manufacturer guidelines regarding the use of mechanical lifts, including the frequent use of only one staff member for transfers that required two, and improper use of equipment such as not ensuring the sling belt was snug. These actions and inactions directly led to resident injuries, including a fractured thumb and a fall from a mechanical lift.
Repeated Deficiencies in QAPI Program and Resident Care Processes
Penalty
Summary
The facility failed to ensure a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified during both annual surveys and complaint investigations. These deficiencies included issues with comprehensive assessments and their timing, assessments after significant changes, quarterly assessments, encoding and transmitting resident assessments, development and implementation of care plans, provision of services meeting professional standards, quality of care, the QAPI program and plan itself, and infection prevention and control. The facility's QAPI plan outlined responsibilities for oversight, resource allocation, problem identification, corrective actions, and staff training, but these measures were not effectively implemented, as shown by the recurrence of the same deficiencies. During an interview, the Administrator acknowledged ongoing performance improvement plans (PIPs) related to MDS (Minimum Data Set) and resident falls, both initiated recently. The Administrator also noted staff turnover, with two staff members previously hired for these areas no longer employed at the facility, and a third-party service now managing MDS and care plans. Despite these efforts, the facility continued to experience repeated deficiencies in key areas of resident assessment, care planning, and infection control, indicating that the QAPI program was not functioning as required at the time of the survey.
Failure to Complete and Submit Required MDS Assessments
Penalty
Summary
The facility failed to complete and/or submit Minimum Data Set (MDS) assessments in a timely manner for four residents. For one resident, after being sent to the emergency room and subsequently admitted to the hospital, the facility did not complete a required discharge assessment. Another resident's End of Prospective Payment System (PPS) Part A Stay MDS assessment remained in progress and was not submitted as required. A third resident's admission MDS assessment was also left in progress and not submitted as completed. Additionally, for a resident who died in the facility, the required Death in Facility MDS tracking record was not completed. The administrator confirmed that these assessments were not completed or submitted as required, noting that MDS assessments were not being completed prior to her tenure. The findings were based on record review, staff interviews, and reference to the MDS 3.0 Resident Assessment Instrument User's Manual.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents with specific clinical needs, as required by policy. For one resident with a diagnosis of anemia, coronary artery disease, and heart failure, who experienced shortness of breath when lying flat, a physician order for nightly CPAP use was not reflected in the care plan. Observation confirmed the resident was not using the CPAP, and the resident reported inconsistent use. The Assistant Director of Nursing acknowledged the omission of the CPAP in the care plan. Another resident with COPD, respiratory failure, and a catheter placed during a recent hospitalization did not have a timely or accurately dated care plan for catheter management. The DON admitted to backdating the care plan due to her absence and lack of education on proper care plan documentation. A third resident with hypertension, dementia, and coronary artery disease experienced an unwitnessed fall, but the care plan interventions, such as a reminder sign to wait for staff assistance, were not promptly or accurately documented. Additionally, a resident with a history of stroke, cancer, and hypertension, who was admitted to hospice care, lacked a care plan detailing the hospice provider and services being delivered. Staff interviews revealed ongoing challenges with staff turnover, training, and maintaining up-to-date care plans, contributing to these deficiencies.
Failure to Develop and Update Individualized Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and maintain individualized, resident-specific care plans for four residents, as required by regulation and facility policy. For one resident with renal insufficiency, peripheral vascular disease, and a history of hip fracture, the care plan did not address skin conditions or interventions to prevent pressure sores, despite the resident requiring pressure-reducing devices and later reporting discomfort from a sore. Observation confirmed the absence of a pressure-reducing device in the resident's chair, and the resident was found sitting directly on a vinyl seat. Another resident with multiple diagnoses, including coronary artery disease, diabetes, and limited mobility, experienced a fall from a mechanical lift (Sit to Stand) during a transfer. The care plan did not include the use of the mechanical lift or specific interventions for changes in the resident's status, even though staff used the device when the resident was too weak to stand. Staff interviews revealed uncertainty about whether the use of the mechanical lift should have been included in the care plan and acknowledged that monitoring for changes in status and appropriate steps were not documented. For a resident with seizure disorder, anxiety, depression, and bipolar disorder, the care plan failed to document the behaviors displayed, non-pharmacological interventions, or targeted behaviors for staff to monitor, despite the resident receiving multiple psychotropic medications. Another resident with severe cognitive impairment and behavioral symptoms had a care plan that did not reflect the current use of an EZ Stand mechanical lift for transfers, even though staff and therapy records indicated its use. The care plan also did not address the resident's refusal to use transfer aids or the need for increased staff assistance during transfers. Facility policies required care plans to be based on comprehensive assessments and updated with changes in resident condition, but these requirements were not met for the residents reviewed.
Failure to Monitor Expired Medications and Document Insulin Pen Open Dates
Penalty
Summary
The facility failed to properly monitor and document pharmaceutical services for residents, specifically regarding expired medications and the lack of open dates on insulin pens. During observations, it was found that hydrocodone prescribed to two residents had expired based on the delivery and expiration dates, and several insulin pens for four residents were present in the medication cart without documentation of the dates they were opened. Staff interviews revealed that nurses relied on pharmacy labeling or a general rule of six months from delivery for medication expiration, and did not consistently document or verify medication details during shift changes. Additionally, the process for counting and verifying Schedule II medications was not thorough, as staff did not check the medication names or resident names, only the pill counts. The facility's policies required staff to record open dates on medication containers and promptly return expired medications to the pharmacy, as well as label insulin pens with the date opened. These procedures were not followed, resulting in expired medications remaining in use and insulin pens lacking required documentation.
Failure to Complete Timely Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive Minimum Data Set (MDS) assessments as required by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual for three out of four residents reviewed. Specifically, the annual and admission MDS assessments were either incomplete or still in progress for multiple residents. For one resident, the admission assessment was accepted, but all subsequent assessments over a period of more than a year were incomplete. Another resident's annual assessment was overdue and still in progress at the time of the survey. A third resident's admission/Medicare 5-day assessment was also found to be in progress and not completed at the time of review. The administrator acknowledged that there were significant staffing issues which resulted in the failure to complete the required MDS assessments. She indicated that while she was initiating the assessments, the responsibility for completion was not clearly assigned due to her working in a different building and staff shortages, leading to a backlog and missed assessment deadlines. The facility had a census of 47 residents at the time of the survey.
Delayed Completion of Significant Change MDS After Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment within the required 14-day timeframe after recognizing a significant change in condition for one resident. The resident, who had diagnoses of stroke, cancer, and hypertension and was cognitively intact, was readmitted to the facility following hospitalization and was admitted to hospice care. Documentation showed that the significant change MDS was initiated seven days after hospice admission and not completed until 23 days after the resident's return, exceeding the regulatory requirement. Additionally, the care plan lacked documentation regarding the hospice provider and services being delivered. Staff interviews confirmed that significant change MDS assessments are triggered automatically upon hospice admission, but the assessment was not completed within the mandated period.
Failure to Complete Required Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete Quarterly Minimum Data Set (MDS) assessments as required by the Centers for Medicare and Medicaid Services (CMS) for three residents. For one resident, a Quarterly MDS assessment was completed five months after the previous assessment, exceeding the required three-month interval. Another resident had a Quarterly MDS assessment completed five months after the Admission MDS, also outside the mandated timeframe. In both cases, the Administrator confirmed that the assessments were not completed within the required period, noting that MDS assessments were not being finished and that staff would enter information for their sections but not complete the process. A third resident's record showed that after the Admission MDS, the facility started but did not complete documentation on subsequent quarterly assessments, with the next accepted MDS not occurring until a significant change assessment much later. The Administrator attributed these failures to changes in facility leadership and MDS staffing, which led to missed MDS requirements, including quarterly assessments. Facility policy and CMS guidelines both require that quarterly MDS assessments be completed at least every 92 days, a standard that was not met for these residents.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to provide an accurate assessment for one resident, as evidenced by discrepancies in the Minimum Data Set (MDS) documentation. The MDS for the resident indicated diagnoses of stroke, cancer, and hypertension, and recorded a Brief Interview for Mental Status (BIMS) score of 15, showing no cognitive impairment. The same MDS documented the presence of a stage 2 pressure ulcer. However, interviews with the Director of Nursing (DON) and another staff member revealed that the resident did not have a pressure ulcer, but rather a laceration, and that the documentation was incorrect. The facility also lacked a policy on maintaining accurate resident records.
Failure to Provide Written Baseline Care Plan to Residents Upon Admission
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to three residents upon admission, as required. For each of these residents, the clinical record review showed that there was no documentation that staff reviewed the initial care plan with the resident or their representative, nor was a copy of the baseline care plan provided. The residents involved had various diagnoses, including chronic obstructive pulmonary disease, respiratory failure, hypertension, non-Alzheimer's dementia, coronary artery disease, anxiety disorder, and insomnia. Cognitive status ranged from no impairment to moderate impairment, with one resident unable to complete the BIMS due to rarely or never being understood. Facility policy required that a preliminary care plan be developed within 24 hours of admission to ensure residents' needs are met. However, staff interviews revealed that the facility considered the kardex sheet placed in the resident's room as the baseline care plan, but did not retain these documents or provide them to residents or their representatives. The Director of Nursing confirmed that the kardex was not offered to residents or families and that the original admission kardex was not kept when updated, resulting in a lack of documentation for the baseline care plan review and provision.
Failure to Change and Label Oxygen Tubing for Resident on Supplemental Oxygen
Penalty
Summary
Facility staff failed to change and label oxygen tubing for a resident with chronic obstructive pulmonary disease (COPD), respiratory failure, and dependence on supplemental oxygen. Multiple observations over several days showed the resident wearing oxygen tubing that lacked a date of application. The resident reported having to argue with staff to use her CPAP machine during naps and sleep. Staff interviews revealed inconsistent information regarding the frequency of oxygen tubing changes, with one staff member stating it was done monthly and another later clarifying it was done weekly. Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed no orders for changing oxygen tubing, and the facility was unable to provide a policy regarding the changing and documentation of oxygen tubing. The deficiency was identified through direct observation, resident interview, and review of facility records, which confirmed that the required documentation and labeling of oxygen tubing were not being performed. The lack of clear orders and policy, as well as inconsistent staff statements, contributed to the failure to provide safe and appropriate respiratory care for the resident.
Failure to Implement Infection Control Practices During Care of Residents with Medical Devices
Penalty
Summary
Staff failed to implement proper infection control practices for two residents. For one resident with an abdominal feeding tube and on continuous oxygen, an LPN administered nutrition and medications via the feeding tube while only wearing gloves and not donning a gown as required by the facility's Enhanced Barrier Precautions policy. During the procedure, the LPN also stepped on the resident's oxygen tubing, which was lying on the floor, and placed the tip of the feeding tube inside the bag of nutritional supplement, both of which were identified as infection control concerns. The resident was NPO, at risk for aspiration, and had multiple comorbidities including use of antipsychotic, antidepressant, diuretic, and antiplatelet medications. In a separate incident, another resident's urinary catheter bag was observed lying directly on the floor without a privacy cover. The facility did not provide a policy regarding catheter bags not touching the floor, but the Director of Nursing confirmed that the catheter bag should never be on the floor. These observations indicate lapses in infection prevention and control practices during the care of residents with indwelling medical devices.
Failure to Treat Resident with Dignity During Personal Care
Penalty
Summary
A resident with a history of heart failure, Parkinson's disease, depression, osteoarthritis, and chronic pain, and who was assessed as cognitively intact, required assistance with personal care due to tremors and weakness. The resident reported that during an episode of care, a staff member with braided hair was wiping her face and eyes so forcefully that it caused pain and resulted in bruising around her eye. Despite the resident's request for the staff member to stop due to pain, the staff member continued the action. The resident later reported soreness and visible bruising was documented by nursing staff. Interviews with the resident confirmed that she experienced pain and bruising after the incident, and she stated that she had told the staff member to stop, but her request was ignored. The resident could not recall the staff member's name but described her appearance. Nursing staff and the social worker corroborated the resident's account, noting the presence of bruising and the resident's report of pain. The incident was reported to facility leadership, and the resident indicated that she had not experienced similar issues since that time. Staff interviews revealed that the CNA in question did not recall the incident or being informed by the resident of any pain. The Director of Nursing confirmed that the resident was considered reliable and that the description matched only one staff member on duty at the time. The facility's policy states that residents have the right to be treated with dignity and respect, and the method for washing a resident's eyes should be gentle, starting from the inner to the outer corner with a warm cloth.
Failure to Follow Physician Orders and Document Interventions
Penalty
Summary
Staff failed to follow physician orders for two residents, resulting in deficiencies in care. For one resident with a history of hypertension, renal insufficiency, and peripheral vascular disease, staff were required to monitor blood pressure daily and notify the primary care provider if readings were outside the specified range. Despite multiple instances of elevated blood pressure above the ordered threshold, there was no documentation that the physician was contacted as required. This omission was confirmed by a hand-written physician order noting the lack of notification and subsequent adjustment of hypertension medication. Another resident with severe cognitive impairment, multiple comorbidities, and a history of behavioral symptoms had physician orders for PRN anti-anxiety medication, with instructions to document non-pharmacological interventions prior to administration and to monitor for side effects and effectiveness. Review of the medication administration record and progress notes revealed that staff administered PRN lorazepam on numerous occasions for agitation, restlessness, and aggression, but consistently failed to document any non-pharmacological interventions attempted before medication was given. Progress notes also lacked required behavior documentation associated with each administration. Interviews with nursing staff and the Director of Nursing confirmed that staff were expected to attempt and document non-pharmacological interventions prior to administering PRN medications for behavior, and to record these actions in the resident's chart. However, record review demonstrated that this documentation was not consistently completed, resulting in a failure to meet professional standards of quality and to follow physician orders as required.
Failure to Provide Timely Assessment and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. One resident with a history of hip fracture and cerebrovascular accident experienced a fall and complained of pain, but staff did not consistently document neurological assessments or ongoing vital signs after the incident. The resident was not sent to the hospital for observation until several hours later, despite continued complaints of pain, and was later found to have a pelvic fracture. Staff interviews revealed uncertainty about the assessments performed, and the Director of Nursing confirmed the absence of a policy for neurological assessments after falls and could not locate the required documentation in the resident's chart. Two other residents missed multiple doses of prescribed medications because the medications were not available at the facility. One resident, with diagnoses including COPD and respiratory failure, did not receive several doses of fexofenadine and Yupelri inhalation solution over multiple days, and there was no documentation that the physician was notified of these omissions. Progress notes indicated repeated attempts to obtain the medications from the pharmacy, but the medications remained unavailable for an extended period. Another resident, with a history of stroke, cancer, and hypertension, experienced a discrepancy between hospice orders and family wishes regarding the continuation of a supplement. Although the hospice nurse agreed to continue the supplement per family request, the facility's records did not show physician notification or clear documentation of the family's wishes being followed. The Director of Nursing stated that staff should have notified the physician about missed medications and honored the family's request regarding the resident's medication regimen.
Inaccurate Documentation of Care and Failure to Record Required Monitoring
Penalty
Summary
The facility failed to ensure that resident records accurately reflected the care provided for two residents. For one resident with a feeding tube and a history of significant weight loss, the care plan required weekly weights following a physician's order. Although the Medication Administration Record (MAR) indicated that weights were taken and documented, the actual weight record lacked any follow-up weights after the initial order, and there was no evidence that the required monitoring was performed as directed. For another resident with hypertension and an order for daily blood pressure (BP) monitoring and physician notification if BP readings were outside specified parameters, the clinical record showed multiple instances where BP readings exceeded the threshold. Despite this, there was no documentation that the physician had been contacted as required. The MAR showed that nurses checked boxes indicating the provider had been contacted, but the Director of Nursing confirmed that there should have been corresponding documentation in the clinical record, which was absent.
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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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