Pleasant Acres Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Hull, Iowa.
- Location
- 309 Railroad Street, Hull, Iowa 51239
- CMS Provider Number
- 165248
- Inspections on file
- 21
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Pleasant Acres Care Center during CMS and state inspections, most recent first.
Kitchen and dietary sanitation lapses were observed in the food prep and storage areas. Surveyors found debris in refrigerator units, ice build up in freezers, and unlabeled food items, and later observed lime build up on the ice machine plus debris on the snack cart and water cart. The DM reported recent kitchen staffing losses had affected completion of some duties, and stated the items observed required cleaning.
Two residents with intact cognition reported or were observed experiencing lapses in dignity, privacy, and respectful communication. During incontinence care for a resident with muscle weakness, anxiety disorder, and respiratory failure, staff opened and left the room door open while the resident lay in bed with pants at the ankles and only a brief over the perineal area, without using a blanket or privacy curtain, and a CNA told the resident to urinate in the brief after the resident expressed a need to void. Another resident with quadriplegia, anemia, and hyperlipidemia reported repeatedly overhearing staff in the hallway talking about him and other residents in a negative manner, and stated that when he confronted a nurse about this, she became upset and short with him for the remainder of her shift.
A resident was observed in the activity room taking multiple tablets with applesauce while no staff were present, even though the chart had no assessment or order allowing self-administration. The facility policy required observation of medication consumption, and the DON stated the resident should have been supervised because she cannot take her pills without assistance.
A resident with disorientation, delirium, muscle weakness, and a history of falls had repeated falls, but the clinical record lacked neuro checks after some of the incidents. The chart showed neuro checks after one fall, including entries that the resident was sleeping or refused, but no documented neuro checks after two other falls; the DON stated neuro assessments should be completed when the resident is sleeping.
Unsafe transfer during toileting care. Staff applied a gait belt to a resident, but an RN and a CNA lifted the resident to standing and back into the wheelchair by placing their arms under the resident’s armpits instead of using the gait belt. The facility policy required gait belt use for residents who cannot independently ambulate or transfer, and the DON stated the staff should have used the gait belt already on the resident.
BiPAP Equipment Cleaning Schedule Not Established: A resident with OSA, respiratory failure, and obesity used a BiPAP at night, but staff had not established or followed a routine cleaning schedule for the tubing or facemask. The resident stated the equipment had never been cleaned, and the care plan and treatment record contained no cleaning or maintenance instructions. The DON confirmed the facility failed to initiate a cleaning schedule for the BiPAP equipment.
Failure to disinfect a glucometer and perform hand hygiene during blood sugar testing and insulin administration. An RN completed a glucose check for a resident while skipping hand hygiene before gloves, exited with soiled gloves, handled the med cart keys, and returned the glucometer to storage without proper cleansing. During insulin administration, staff again handled the cart and insulin pens with soiled gloves and did not properly disinfect the pens, despite facility policies requiring glucometer disinfection after each use and hand hygiene before and after glove use.
The facility failed to follow the menu and prepare food to meet residents' nutritional needs. A dietary staff member used only one 5-pound bag of chicken for a meal requiring 9 pounds, based on incorrect training. The error was confirmed by the Dietary Manager and the Administrator, who acknowledged the expectation to follow recipes accurately, although no specific policy was in place.
The facility failed to notify the LTC Ombudsman about the hospital transfers of two residents with heart-related conditions. The residents were transferred and returned without their names being included in the facility's monthly notification report. The Administrator acknowledged the omission was due to a report error and the absence of a notification policy.
The facility failed to conduct care plan conferences with two residents and their families, as required by regulations. One resident with severe cognitive impairment had no documented care conferences, and their brother/POA was not informed about participation opportunities. Another resident with no cognitive impairment reported not being invited to care conferences. Staff and the administrator acknowledged the oversight, which was contrary to the facility's policy encouraging resident and family involvement in care planning.
A resident with heart failure, anemia, and peripheral vascular disease did not receive physician-ordered medications, including Coumadin, Bupropion, and Calcitriol, due to unavailability. The facility failed to notify the physician of these missed medications, contrary to their policy. The resident had no cognitive impairment, and the issue was acknowledged by the DON.
The facility failed to respond to call lights in a timely manner for two residents, with documented delays ranging from 16 minutes to over an hour. One resident reported frequent waits over 15 minutes, and another's family noted similar issues, especially on weekends. The facility's administrator confirmed that call lights should be answered within 15 minutes, highlighting a deficiency in meeting this standard.
A facility failed to follow infection prevention practices for a resident with a suprapubic catheter on Enhanced Barrier Precautions (EBP). A CMA was observed performing catheter care without a gown, contrary to EBP guidelines requiring gowns and gloves for high-contact activities. Staff interviews revealed confusion about PPE requirements, with the RN/IP unsure about gown necessity and the DON expecting gown use during catheter care. The facility's policy and CDC guidelines stress the importance of PPE to prevent the spread of multidrug-resistant organisms.
Kitchen and Dietary Area Sanitation Lapses
Penalty
Summary
The facility failed to ensure proper sanitary conditions in the kitchen area where staff prepared food for a census of 37 residents. During the initial kitchen walkthrough on 12/16/26 at 10:35 AM, surveyors observed refrigerator units with scattered food debris, freezer units with ice build up, and food items that were not labeled, including ranch dressing, frozen meat, and frozen pizza. During the initial tour, the Dietary Manager reported the facility had recently lost two kitchen staff, which resulted in some duties not being consistently completed. The Dietary Manager also reported that the bottoms of the refrigerator units required cleaning, the freezers needed defrosting, and all food required proper labeling. On 12/18/26 at 12:42 PM, a tour of the ice machine room showed an ice machine with lime build up on the outside, a snack cart with loose debris build up on top and within the drawers, and a water cart with debris and dry liquid build up. The Dietary Manager stated dietary staff were not responsible for cleaning the ice machine, snack cart, or water cart, but also stated that all of these items required cleaning, including the tray on top of the ice machine. The facility policy stated that all food service areas shall be kept clean, sanitary, and free from litter and that daily and weekly inspections were to be conducted for refrigerators, freezers, storage areas, and other food service areas.
Failure to Maintain Dignity, Privacy, and Respectful Communication
Penalty
Summary
The deficiency involves failures to maintain resident dignity, privacy, and respectful communication during care and staff interactions. For one resident with muscle weakness, anxiety disorder, and respiratory failure, whose MDS documented intact short- and long-term memory, surveyors observed incontinence care during which a CNA used a walkie-talkie to request additional wet wipes. When the RN brought the supplies, the resident was lying in bed with pants at the ankles and only a brief covering the perineal area. Staff did not place a blanket over the resident or pull the privacy curtain before the door was opened, and the door was left open with the resident in the same state of undress after the wipes were placed on the bedside table. During the continuation of incontinence care, when the resident stated, "I need to pee," the CNA responded, "Go ahead and go, you still have your brief on." The resident then paused and said, "Never mind, I don't have to go." These actions occurred despite a facility policy stating that residents are to be treated with respect and dignity and that resident privacy is to be maintained. The deficiency also includes staff communication about residents in a manner that could be overheard and was perceived as disrespectful. A resident with quadriplegia, anemia, hyperlipidemia, and a BIMS score of 15 indicating no memory impairment reported that staff were talking about him in the hallway outside his room and that he could hear them. He stated that the nurse talks badly about other residents, and that when he opened his door and confronted her, she became upset and short with him for the rest of her shift. He further reported that this was not the first time he overheard staff talking about him and other residents, and that he felt frustrated at being labeled crabby or as causing issues when he believed he was standing up for himself and other residents. The Administrator acknowledged that staff should not be discussing residents in the hallways.
Unsupervised Medication Self-Administration
Penalty
Summary
The facility failed to ensure safe self-administration of medications for Resident #26 and failed to monitor the resident while she took medications, despite no assessment or order in the medical record authorizing self-administration. During observation on 02/18/2026 at 8:31 a.m., Resident #26 was sitting in the activity room with two medication cups in front of her; one cup contained applesauce with a spoon, and the other contained a variety of tablets. The resident dumped the tablets onto the table, lined them up, and took them with the applesauce while no facility staff were in or around the area. Review of the resident’s chart showed no documentation of an assessment for self-administration and no orders for self-administration of medications. The facility’s Medication Administration policy stated that resident consumption of medications should be observed, and the DON stated in interview that the resident should have had someone watching her take her medications because she cannot take her pills without supervision.
Missing Neurological Checks After Falls
Penalty
Summary
The facility failed to complete neurological checks after a resident fell for 1 of 1 residents reviewed. Resident #11’s MDS documented disorientation, delirium due to a known psychosocial condition, muscle weakness, and a history of falling, and the BIMS score was not assessed. The incident log showed falls on 1/21/26, 1/25/26, 1/27/26, and 2/13/26. The clinical record showed neurological checks documented after the 1/21/26 fall, including repeated entries noting the resident was sleeping or refused checks while in a wheelchair. However, the record lacked documentation of neurological checks after the 1/25/26 and 1/27/26 falls. After the 2/13/26 fall, neurological checks were documented beginning at 10:30 p.m. and continued through 2:00 a.m., with entries noting the resident was sleeping, awake, or exhibiting behaviors. The facility’s Head Injury policy required assessment after a known, suspected, or verbalized head injury, including neurological evaluation for changes in physical functioning, behavior, cognition, level of consciousness, dizziness, nausea, irritability, slurred speech, or slow responses, and the DON stated the neurological assessment should be completed when the resident is sleeping.
Unsafe Transfer During Toileting Care
Penalty
Summary
The facility failed to provide safe transfers for Resident #11 during toileting care. Staff D, a CNA, applied a gait belt to the resident, but Staff B, an RN, and Staff E, a CNA, assisted the resident to a standing position with their arms under the resident’s armpits instead of using the gait belt. After the resident finished using the toilet, Staff B and Staff E again lifted the resident to standing with their arms under the armpits while Staff D provided perineal care, and then Staff B and Staff E assisted the resident back into the wheelchair without using the gait belt. The facility policy titled Use of Gait Belt, dated 2025, stated gait belts are to be used with residents who cannot independently ambulate or transfer for safety. The DON stated the staff should not have been lifting under the resident’s arms and should have used the gait belt already on the resident.
BiPAP Equipment Cleaning Schedule Not Established
Penalty
Summary
The facility failed to implement and practice appropriate infection control measures for a resident’s BiPAP machine by not establishing or following a routine cleaning schedule. Resident #7 had diagnoses of obstructive sleep apnea, respiratory failure, and obesity, and the MDS documented use of a non-invasive mechanical ventilator with a BIMS score of 15. During observation, a BiPAP machine was present on the resident’s bedside table, and the resident stated staff had never cleaned the BiPAP oxygen tubing or facemask, despite having used the device for about a year and a half. Record review showed a physician order for BiPAP use at night, but the care plan and February 2026 treatment record contained no instructions regarding cleaning or maintenance of the BiPAP equipment. The facility’s CPAP/BiPAP Cleaning policy required cleaning in accordance with CDC guidelines and manufacturer recommendations, including routine cleaning of the mask, tubing, and other components. The DON stated the facility failed to initiate a cleaning schedule for the resident’s BiPAP equipment and confirmed that CPAP and BiPAP equipment should have a regular cleaning schedule.
Failure to Disinfect Glucometer and Perform Hand Hygiene During Blood Sugar Testing and Insulin Administration
Penalty
Summary
The facility failed to perform blood sugar testing and administer insulin in a manner that protected a resident from bloodborne pathogens for 1 of 1 residents reviewed. During observation, Staff C, RN, removed Resident #7’s glucometer and testing supplies from the medication cart, entered the resident’s room, and completed the glucose check without performing hand hygiene before donning gloves. After discarding the used disposable supplies, Staff C exited the room wearing soiled gloves while holding the glucometer, returned to the medication cart, removed one glove, failed to perform hand hygiene, retrieved the medication cart keys from a scrub pocket, and unlocked the cart. Staff A then returned the glucometer to the storage container without proper cleansing. Later, Staff A retrieved insulin pens, needles, and supplies and entered the resident’s room to administer insulin. After insulin administration, Staff C again exited the room wearing soiled gloves, removed one glove, failed to perform hand hygiene, retrieved the medication cart keys from a scrub pocket, unlocked the cart, and placed insulin pens in a drawer without properly disinfecting the pens. The facility’s Glucometer Disinfection policy required glucometers to be cleaned and disinfected after each use, and the Hand Hygiene policy stated that staff must perform hand hygiene before donning gloves and immediately after removing gloves. In interview, the DON stated staff were required to disinfect glucometers using disinfecting wipes and to clean insulin pens as needed, and that hand hygiene should be performed before donning gloves and immediately after doffing gloves.
Failure to Follow Menu and Recipe for Nutritional Needs
Penalty
Summary
The facility failed to follow the menu and prepare food to meet the residents' nutritional needs. On a specific date, Staff D, a dietary staff member, used only one bag of diced chicken for a lunch meal intended to serve 36 portions of Chicken Alfredo. The recipe required 9 pounds of chicken, but Staff D used only one 5-pound bag, mistakenly believing it was the correct amount based on training received. This discrepancy was confirmed through observation of the packaging and review of the recipe, which clearly documented the need for 9 pounds of chicken. The Dietary Manager, Staff C, acknowledged the error, confirming that two 5-pound bags were available in each box and that 1.75 bags should have been used for the recipe. The facility's policy on portion control was reviewed, which stated that foods should be served according to standard portion sizes to ensure adequate servings. The Administrator confirmed the expectation that recipes be followed accurately, although there was no specific policy regarding adherence to recipe ingredient amounts. The facility census at the time was 27 residents.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman regarding the transfer of two residents to the hospital. Resident #4, who had diagnoses of heart failure, anemia, and peripheral vascular disease, was transferred to the hospital on February 5, 2024, and returned on February 19, 2024. The facility's documentation, specifically the Notice of Transfer Form to the Long Term Care Ombudsman for February 2024, did not include Resident #4's name, indicating a failure in the notification process. Similarly, Resident #15, with diagnoses of atrial fibrillation, heart failure, and COPD, was transferred to the hospital on May 25, 2024, and returned on June 3, 2024. The facility's Notice of Transfer Form for May 2024 also lacked Resident #15's name. Interviews with the Administrator revealed that the omission was due to a report that did not include these residents' names, and the facility did not have a policy on notification to the Ombudsman, although they submitted reports monthly.
Failure to Conduct Care Plan Conferences with Residents and Families
Penalty
Summary
The facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team, including the resident and their representative, for two residents. Resident #14, who was documented as having severe cognitive impairment, had no care conferences documented with family or resident present. The resident's brother and power of attorney stated that he was not informed about the possibility of participating in care conferences and expressed a desire to be involved. Resident #19, who had no cognitive impairment, also reported not being invited to care conferences since residing at the facility. Staff B, a registered nurse and infection preventionist, acknowledged that care conferences had not been completed with these residents or their families. The facility's administrator confirmed that care plan conferences had not been conducted in accordance with regulations and that the facility was working to address this issue. The facility's policy encourages resident and family participation in care planning, but this was not adhered to in these cases.
Failure to Administer and Notify Physician of Missed Medications
Penalty
Summary
The facility failed to provide physician-ordered medications and did not notify the physician of missed medications for a resident diagnosed with heart failure, anemia, and peripheral vascular disease. The resident, who had no cognitive impairment, had orders for Coumadin, Bupropion, and Calcitriol. However, the facility's records showed multiple instances where these medications were not available or not administered over several days. Specifically, Coumadin was not available on multiple occasions, and Bupropion and Calcitriol were also noted as not available or on order. The facility's policy requires prompt notification of the provider in case of significant medication errors or adverse consequences. Despite this, the Electronic Health Records did not indicate any physician notification for the missed medications on the specified dates. An interview with the Director of Nursing revealed that there are times when medications do not arrive on time, and it was acknowledged that missed medications should be documented, and the physician should be notified, which was not done in this case.
Delayed Call Light Responses in LTC Facility
Penalty
Summary
The facility failed to ensure timely responses to call lights for two residents, leading to prolonged wait times. Resident #4 reported experiencing delays of over 15 minutes on several occasions. A review of the facility's Alarm Event Report from 12/4/24 to 12/11/24 showed multiple instances where call lights were left unanswered for extended periods, ranging from 16 minutes to over an hour. Specific incidents included a call light on 12/8/24 that was on for 1 hour and 7 minutes and another on 12/9/24 that was on for 51 minutes. Resident #23's family also reported delays in call light responses, particularly on weekends, with waits exceeding 15 minutes. The Alarm Event Report corroborated these claims, showing a call light on 12/7/24 that was on for 55 minutes and another on 12/8/24 for 26 minutes. The facility's administrator acknowledged that call lights should be answered within 15 minutes, indicating a failure to meet this standard during the reported period.
Inadequate Use of PPE During Catheter Care
Penalty
Summary
The facility failed to adhere to appropriate infection prevention practices for a resident with a suprapubic catheter who was on Enhanced Barrier Precautions (EBP). During an observation, a Certified Medication Assistant (CMA) was seen performing catheter care for the resident without wearing a gown, which is required under EBP guidelines. The CMA did wear gloves and a mask, but the absence of a gown during the procedure was noted. The facility's policy on EBP, which requires the use of gowns and gloves during high-contact resident care activities, was not followed in this instance. Interviews with staff revealed a lack of clarity and understanding regarding the requirements for PPE during catheter care. The Registered Nurse/Infection Preventionist was unsure if a gown was necessary, and the Director of Nursing (DON) confirmed that the facility's expectation was for a gown to be worn during all catheter care. The facility's policy and the CDC guidelines both emphasize the importance of using gowns and gloves to prevent the spread of multidrug-resistant organisms, especially for residents with indwelling medical devices.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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