Prestige Care Center Of Fairfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfield, Iowa.
- Location
- 400 Highland Street, Fairfield, Iowa 52556
- CMS Provider Number
- 165602
- Inspections on file
- 31
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Prestige Care Center Of Fairfield during CMS and state inspections, most recent first.
Multiple residents experienced unsafe conditions, including being left unattended in a shower chair, being knocked down by another resident in a wheelchair, and falling from a mechanical lift due to improper equipment use. Staff shortages, inadequate supervision, and lack of appropriate interventions contributed to these incidents. Additionally, oxygen tanks were observed being transported without proper securing, violating facility policy.
The facility did not ensure continuous on-site coverage by CPR-certified staff, as required by policy. Review of staff schedules and certification lists showed multiple shifts, especially overnight and on weekends, without a CPR-certified staff member present. Leadership acknowledged awareness of these coverage gaps, though no residents required CPR during the period reviewed.
Multiple residents did not receive medications as directed by professional standards or manufacturer/pharmacist instructions. For example, a resident with diabetes received insulin without timely access to food, another had medications set up by a CMA but administered by an RN, and a resident prescribed levothyroxine received it with other medications instead of separately. Additionally, morning medications for a resident with a G-tube were given significantly later than scheduled. These deficiencies were confirmed through observation, record review, and staff interviews.
Surveyors found that insufficient staffing led to delayed responses to call lights, with some residents waiting over 30 minutes for assistance with mobility, toileting, and repositioning. Staff interviews confirmed that reduced staffing levels contributed to these delays, and residents with significant care needs were left unattended for extended periods.
Surveyors found unsanitary kitchen conditions, including dirty equipment, food debris, and improper glove use during meal preparation. The Dietary Manager and staff handled multiple surfaces and utensils with the same gloves before serving food to residents, and cleaning schedules were inconsistent and incomplete. Facility policies for hand hygiene and sanitation were not consistently followed.
A resident with moderately impaired cognition had conflicting documentation regarding code status, with both DNR and full code orders present in the medical record and code status book. Staff interviews revealed confusion about the resident's current wishes, and the resident was unable to clearly communicate her preference, requesting staff to consult her family. The facility did not consistently follow its policy on advance directives and CPR documentation.
A resident with severe cognitive impairment and multiple diagnoses developed a deep tissue injury to the right heel. Despite care plan orders and provider instructions to offload pressure using heel protectors, staff repeatedly failed to ensure the resident wore the required devices, leaving the heel in contact with the mattress. Observations confirmed the lack of intervention, and the DON acknowledged staff responsibility to provide heel protectors.
A resident with ESRD who received dialysis did not have post dialysis assessments consistently completed and documented as required by facility policy. Staff interviews confirmed that both pre and post dialysis assessments should have been performed and recorded, but electronic health records showed missing post dialysis assessments on multiple occasions.
The facility did not update its Facility Assessment to reflect the needs of residents receiving hemodialysis and those with G-tubes, despite having several such residents in care. The assessment lacked identification of required specialized staff training and medical supplies, even though the facility's policy and leadership recognized these needs and the importance of updating the assessment with changes in resident care requirements.
A resident with severe cognitive impairment and frequent urinary incontinence was found to have a persistent urine odor in their room, despite daily linen changes and cleaning efforts by staff. Staff interviews and observations confirmed the odor was ongoing, with wet areas noted in the bathroom and incomplete resolution of the issue, contrary to facility policy requiring a sanitary and comfortable environment.
Staff did not provide a meal in a timely manner to a resident with intact cognition, resulting in distress, and failed to use a dignity cover for a catheter bag for another resident with severe cognitive impairment. Nursing staff and the DON confirmed that catheter bag covers were not available, and facility policy required their use to promote dignity.
The facility did not complete required self-medication administration assessments for two residents—one with diabetes and another with severe allergies and an order for an EpiPen at bedside. Both residents were either observed with medications at bedside or had orders to self-administer, but there was no documented interdisciplinary assessment as required by facility policy. Staff were also unaware of one resident's allergies and the location of emergency medication.
A resident with severe cognitive impairment and a G-tube was administered medications and tube feeding by an LPN while the room door remained open, exposing the resident's abdomen and G-tube. Staff interviews and facility policy confirmed that privacy should have been maintained during such procedures.
A resident with severe cognitive impairment was routinely administered risperidone without clear documentation or identification of targeted behaviors justifying its use. Clinical records, care plans, and staff interviews indicated the resident did not exhibit significant behavioral disturbances, and the facility failed to specify or monitor behaviors as required by policy for psychotropic medication administration.
The facility did not report multiple allegations of abuse and resident-to-resident altercations within the required timeframe. Incidents included a resident being knocked down and injured by another resident in a wheelchair, a staff member allegedly handling a resident aggressively, and a resident with a history of inappropriate behavior touching another resident. In each case, reporting to authorities was delayed or not documented as required by policy.
A resident with intact cognition was discharged without an ongoing discharge planning process, as required documentation and care plan updates were missing, and discharge notifications were not properly completed or signed. Facility administrators provided inconsistent accounts of the discharge process, and there was no evidence that the resident was adequately prepared for a safe transfer, as outlined in facility policy.
The facility did not update care plans to address significant weight loss, severe allergies, wheelchair safety, and changes in advanced directive status for several residents. For example, a resident with notable weight loss did not have this addressed in their care plan, another involved in a wheelchair incident lacked additional safety interventions, a resident's change to DNR status was not reflected in the care plan, and a resident with severe allergies had no care plan interventions or documentation for EpiPen use.
Two residents dependent on staff for bathing did not receive the required number of baths, with documentation showing missed or delayed bathing and lack of follow-up when baths were not provided. One resident was cognitively intact and denied refusing care, while the other had moderate cognitive impairment and multiple medical conditions, including pressure ulcers. Staff interviews and documentation confirmed gaps in bathing care, contrary to facility policy.
Two residents with diabetes experienced multiple episodes of hyperglycemia, with blood sugar readings exceeding 399 mg/dl, but staff failed to document provider notifications or follow-up interventions as required by care plans and medication orders. Staff interviews revealed inconsistent practices regarding provider notification, and the DON acknowledged inadequate documentation.
A resident with an indwelling urinary catheter did not receive proper infection control and catheter care, including inconsistent use of Enhanced Barrier Precautions, improper hand hygiene, and failure to use appropriate anchoring devices. Staff used improper cleaning techniques, did not promptly address a leaking catheter bag, and did not follow facility policy for catheter care, resulting in continued discomfort and risk of infection for the resident.
A resident with severe cognitive impairment, hemiplegia, and a feeding tube experienced a significant, rapid weight loss. Facility staff did not clarify discrepancies in weight records, failed to document a required weekly weight, and did not notify the physician or implement interventions in a timely manner, despite care plan and policy requirements. Staff interviews confirmed inconsistent monitoring and lack of follow-up on the resident's weight changes.
A resident with multiple medical conditions and intact cognition requested physical therapy to improve mobility, but the facility did not document any follow-up or provision of therapy services after the initial request, despite policy requiring such services.
Surveyors found that the facility did not post daily nurse staffing and census information in a visible area as required by policy. The Administrator confirmed the absence of the posting, and the Staffing Coordinator reported she was unaware of her responsibility to post this information. Facility policy requires this information to be posted daily and accessible to residents, staff, and visitors.
A resident with atrial fibrillation and a prosthetic heart valve received unnecessary doses of warfarin after staff failed to follow physician orders to hold the medication following elevated INR results. Despite clear orders and facility policy, the resident continued to receive warfarin, resulting in a critically high INR and subsequent hospital admission. Staff interviews revealed confusion and lack of clarity regarding medication hold procedures and documentation.
The facility failed to maintain a clean and sanitary environment, as observed in the rooms of two residents requiring maximal assistance. One resident reported her room was filthy, with gritty floors and debris on the toilet. Another resident's room was found dirty, with unswept and unmopped bathroom floors. Despite cleaning efforts by a housekeeper, issues persisted, and the Housekeeper Director could not provide records of monthly deep cleaning.
The facility failed to follow its policy requiring two licensed nurses to conduct shift change narcotic counts, leading to discrepancies in narcotic counts. A Certified Medication Aide completed a count alone and left keys unsecured, a practice noted as common. A Registered Nurse also counted narcotics alone and passed keys without a proper count, resulting in missing narcotics, including Hydrocodone/APAP and Morphine sulfate, discovered by another aide. The discrepancies were reported to the Administrator and DON.
A facility failed to secure medication cart keys, allowing unauthorized access and resulting in missing narcotics. Staff C, a Certified Medication Aide, left keys in an unlocked drawer, leading to Staff A accessing the cart. The next day, Staff E found missing Hydrocodone/APAP and Morphine sulfate from two residents' supplies, and later, an entire bubble pack of Oxycodone was missing. The facility did not follow its policy requiring two licensed nurses to account for controlled substances and keys at shift changes.
The facility failed to accurately code medications and services in the MDS assessments for four residents. A resident's MDS inaccurately coded insulin use, another's failed to indicate hospice services, and two residents' MDS assessments incorrectly listed anticoagulant medication use instead of antiplatelet medication. These discrepancies highlight the facility's failure to ensure accurate MDS coding, impacting the care and services provided to the residents.
The facility failed to provide comprehensive individualized care plans for four residents, omitting critical aspects such as diabetes management, oxygen therapy, wound care, and hospice services. These omissions were identified through observations, interviews, and record reviews, highlighting a lack of specific interventions and documentation in the care plans.
A long-term care facility failed to provide adequate staffing during lunch, resulting in insufficient assistance for residents with eating and toileting needs. An LPN was the only staff member present, leading to an incontinent episode for a resident with severe cognitive impairment. Other residents reported long wait times for assistance and medication errors, highlighting the staffing issues. Interviews with staff revealed that the facility was short-staffed due to a CNA attending an appointment, impacting the quality of care provided.
The facility did not follow the prescribed pureed diet menu, omitting pureed cornbread from a meal. A cook prepared the meal without pureeing the cornbread, despite it being listed on the Week 4 Wednesday Diet Spreadsheet. The Dietary Manager acknowledged the oversight, noting that the cornbread might have been missed. The facility's guidelines required adherence to written menus and standardized recipes, which were not followed.
The facility failed to maintain kitchen sanitation and proper food safety practices. Observations included unsanitary storage of food items, such as open bags of hamburger and undated sour cream, and inadequate testing of dishwasher temperature and chemical levels. Additionally, dietary staff transported uncovered plates of food to residents' rooms due to a lack of lids, with the Dietary Manager suggesting the use of foil as a temporary measure.
A resident with intact cognition and chronic kidney disease was not given meal choices, contrary to facility policy. The resident reported receiving meals without being consulted, and staff interviews revealed inconsistencies in offering meal options. The Dietary Manager admitted that meal preferences were not always documented, and some residents were missed, leading to a deficiency in supporting resident choice.
A resident with moderately impaired cognition was hospitalized and returned the next day, but the facility failed to notify the Ombudsman as required. The Social Worker was trained to notify only for overnight stays, contrary to the facility's policy that required notification for emergency transfers.
The facility failed to follow PASRR Level II recommendations for two residents, including not designating a POA for a resident with schizophrenia and submitting a PASRR Level I screen almost a year late for a resident with mental health diagnoses. Staff interviews revealed misunderstandings of PASRR requirements, leading to federal compliance issues.
The facility failed to ensure proper medication administration for two residents, leading to deficiencies in professional standards of care. A CMA administered medications without proper documentation and used another staff member's login, while another resident received incorrect medications multiple times. The facility's policy on medication administration was not followed, resulting in medication errors.
The facility failed to follow bowel management protocols for a resident with impaired cognition, resulting in a lack of bowel movements over several days without administering prescribed medications. Additionally, the facility did not adequately assess and document a diabetic foot ulcer for another resident, leading to discrepancies in treatment orders and documentation. The facility's policies for bowel management and wound care were not adhered to, resulting in deficiencies in resident care.
A resident with Alzheimer's and fragile skin was injured during repositioning in bed when their head hit the bed rail, resulting in a bruise. Despite the care plan's instructions to use caution, the resident's resistance and positioning too close to the bed's edge contributed to the incident. Staff interviews highlighted challenges in moving the resident safely.
A resident with severe cognitive impairment and multiple health conditions was not provided with continuous oxygen therapy as ordered by the physician. Observations showed the resident without oxygen in the dining room, despite having an order for continuous administration. Staff noted the resident's non-compliance with wearing the oxygen tubing, and the DON suggested asking the resident if they wanted to wear oxygen while eating, rather than ensuring adherence to the physician's order.
The facility failed to effectively address previously identified quality deficiencies, resulting in repeat citations for issues such as MDS accuracy, care plan timing, professional standards, and more. Despite efforts to update processes, the facility continued to receive similar citations across multiple surveys.
The facility failed to serve mandarin oranges and room trays at the appropriate temperatures and did not maintain proper hygiene practices during food handling. The cook used gloved hands to move food items on plates without changing gloves or washing hands, and food temperatures were not within the required ranges.
The facility failed to notify the physician when a resident's blood glucose levels exceeded 450 mg/dl on multiple occasions. Despite the facility's policy, there was no documentation that the physician was informed of these elevated readings. Staff interviews confirmed that while the protocol was to notify the physician, the notifications were not consistently documented.
A resident with cerebral palsy waited approximately 48 minutes for assistance after activating her call light, despite the facility's policy requiring a response within 15 minutes. Staff interviews revealed inconsistencies in understanding the required response time, and the Director of Nursing acknowledged exceptions when multiple lights were on.
Failure to Prevent Accidents and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for several residents. One resident with Alzheimer's disease, dementia, and Parkinson's disease, who was severely cognitively impaired and at risk for falls, was left unattended in a shower chair for an extended period. Staff interviews confirmed that the resident required two staff for transfers, but due to short staffing, she remained in the chair for a prolonged time, resulting in red indentations on her leg. Staff and the DON acknowledged that residents should not be left alone in shower chairs. Another incident involved a resident with severe cognitive impairment and gait abnormalities who was knocked down by another resident in a wheelchair, resulting in a large hematoma to the back of her head and a headache. The resident was transferred to the ER and later returned. The resident who caused the incident had a history of unsafe wheelchair use, including propelling himself backwards and running into others. Despite previous behavioral issues and staff concerns, the care plan lacked sufficient interventions to ensure wheelchair safety for this resident and others. Additionally, a resident dependent on staff for transfers fell from a mechanical lift due to the use of an inappropriate sling. Staff involved in the transfer noted that the sling was not the usual type, appeared unsafe, and was not designed for bed-to-chair transfers. Despite concerns raised during the transfer, the process continued, resulting in the resident sliding out of the sling and sustaining a hematoma and abrasion to the head. The facility also failed to ensure oxygen tanks were properly secured during transport, as observed on multiple occasions with staff carrying and setting tanks down without holders, contrary to facility policy.
Failure to Maintain 24/7 CPR-Certified Staff Coverage
Penalty
Summary
The facility failed to ensure that at least one CPR-certified staff member was available on-site 24 hours per day, 7 days per week, as required by facility policy. Review of nursing staff schedules and the list of CPR-certified staff revealed multiple shifts, particularly during third shift and weekends, where no CPR-certified staff were present. Both the Administrator and the DON acknowledged gaps in CPR coverage, with the Administrator specifically noting awareness of shortages during certain shifts and the DON confirming ongoing time gaps in coverage. The facility's policy mandates that CPR-certified staff be available at all times, but this standard was not met on several documented occasions. Interviews with facility leadership confirmed knowledge of the deficiency, and documentation showed that the most updated list of CPR-certified staff had not always been communicated. Despite these lapses, there were no reported incidents during the review period where residents required CPR. The facility census at the time was 59 residents, and the deficiency was identified through review of schedules, staff lists, policy, and staff interviews.
Failure to Administer Medications According to Professional Standards and Prescribed Timeframes
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards and manufacturer or pharmacist directions for several residents. For one resident with diabetes, insulin aspart was administered without ensuring a meal was provided within the recommended 5-10 minutes post-injection, as observed when the resident did not receive food until over 30 minutes after administration. Another resident with multiple medication orders via G-tube had medications set up by a Certified Medication Assistant (CMA) but administered by a Registered Nurse (RN), contrary to professional standards and facility policy that require the same staff member to both set up and administer medications. Additionally, a resident prescribed levothyroxine was not consistently receiving the medication as intended; it was sometimes administered with other medications rather than by itself and not always at the scheduled time, despite pharmacist and facility expectations for it to be given separately and early in the morning. Staff interviews confirmed that the medication was not always administered according to these standards, with both night and day shift nurses involved in the inconsistency. For another resident requiring G-tube medications, multiple morning medications scheduled for 7:00 AM were observed being administered at 9:29 AM, well outside the facility's policy of administering medications within one hour before or after the scheduled time. Staff confirmed that this timing was considered late, and the facility's policy was not followed in this instance. These findings were based on direct observation, record review, and staff interviews, and affected multiple residents with complex medical needs.
Delayed Call Light Response and Insufficient Staffing
Penalty
Summary
Surveyors observed multiple instances where residents' call lights were left unanswered for extended periods, and residents requiring assistance did not receive timely care. On one occasion, two residents' call lights remained activated for over 15 minutes while a CNA attended to another resident, passing by the rooms without responding. Additional residents activated their call lights during this period, and staff were not present in the hallway. When the CNA eventually responded, residents requested assistance with toileting and repositioning, indicating unmet needs during the delay. Facility policy requires all staff to respond promptly to call lights, but this was not followed. A resident with Alzheimer's and Parkinson's disease, who required a mechanical lift and two staff for transfers, was left sitting alone in a shower chair for over 40 minutes due to insufficient staff available to assist with her transfer. Staff interviews confirmed that only two aides were present instead of the usual three, resulting in delays. The resident was eventually transferred to bed, and staff noted red indentations on her leg from prolonged sitting. Staff and the DON acknowledged that residents should not be left in shower chairs and that adequate staffing is necessary to meet residents' needs. Additional interviews with residents and staff revealed frequent delays in call light response, with some residents reporting waits of 30 minutes to over an hour, particularly during shifts with reduced staffing. Residents with significant mobility and cognitive impairments, as well as those dependent on staff for activities of daily living, were affected by these delays. Staff and the DON confirmed that call lights should be answered within 15 minutes, but this standard was not consistently met due to staffing shortages.
Failure to Maintain Sanitary Kitchen Conditions and Prevent Cross Contamination
Penalty
Summary
Surveyors observed multiple unsanitary conditions in the facility's kitchen during two meal preparations. The stove was found with spilled pancake batter, grime, and food crumbs, while the deep fat fryer had baskets coated in grime and dark brown oil. The microwave contained food crumbs and spills, and the dry storage room floor was littered with trash, including plastic spoons, papers, sugar packets, and boxes. An open paper bag of french fries was found in a freezer, with fries spilling onto the bottom. Additional observations revealed dirt and debris on the kitchen floor in several areas, as well as crumbs and debris on the lower shelf with clean sheet pans. During meal preparation, the Dietary Manager (DM) was seen handling multiple objects, such as oven mitts, food thermometers, writing pads, refrigerator doors, and various utensils, with the same pair of gloves, without changing gloves or performing hand hygiene between tasks. The DM then used these gloved hands to handle serving scoops, which were subsequently used to portion food for residents. A similar pattern was observed when the DM prepared mashed potatoes, again touching various surfaces and utensils with the same gloves before using serving scoops to portion food. Additionally, a dietary aide served soup in a bowl that was stacked on a cart with other bowls and plates that had visible dried food residue and crumbs. Interviews with the DM revealed inconsistencies in the cleaning schedule and responsibilities. The DM initially stated that staff followed a daily cleaning schedule, but was only able to provide a blank schedule and later clarified that cleaning tasks were shared among staff. The DM also admitted that the fryer was not included on the cleaning schedule and that the stove top was not cleaned daily. Facility policies required hand washing before food preparation and after contact with unsanitary items, as well as maintaining clean and sanitary food service areas, but these standards were not consistently followed.
Failure to Ensure Consistent Communication and Documentation of Code Status
Penalty
Summary
The facility failed to ensure consistent communication and clarification of a resident's code status, specifically whether to perform cardiopulmonary resuscitation (CPR) or to follow a Do Not Resuscitate (DNR) order. The resident in question had moderately impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Multiple documents in the resident's record, including the care plan, IPOST form, resuscitation designation orders, and physician orders, contained conflicting information regarding the resident's code status. Some records indicated the resident was a full code, while others indicated DNR status. Additionally, staff interviews revealed uncertainty and confusion about the resident's current code status, with staff referencing both full code and DNR in different contexts. Observation of staff interactions with the resident showed that the resident was unable to provide a clear answer regarding her wishes for resuscitation and requested that the nurse follow up with her family. Review of the code status book in the dining room also revealed the presence of both DNR and full code documentation for the same resident. The Director of Nursing acknowledged the mix-up and the need to clarify the correct code status. The facility's policy requires adherence to residents' rights to formulate advance directives and to implement guidelines regarding CPR, but this was not consistently followed in this case.
Failure to Implement Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The facility failed to implement and maintain appropriate interventions to prevent and treat pressure ulcers for a resident identified as being at risk. The resident, who had diagnoses including hemiplegia, dysphagia, and chronic pain syndrome, was assessed as severely cognitively impaired and at risk for pressure ulcers, but had no unhealed ulcers at the time of the initial assessment. Subsequent provider notes documented the development and ongoing presence of a deep tissue injury with eschar on the resident's right heel, with specific orders to offload pressure using heel protectors and to complete wound treatment twice daily. Despite these orders, multiple observations revealed the resident lying in bed without heel protectors, with the right heel in direct contact with the mattress. Staff, including a registered nurse, failed to apply the heel protectors during wound care, and the DON confirmed that staff were expected to ensure residents with pressure ulcers wore boots, locating alternatives if necessary. The facility's policy referenced surveillance for pressure injuries but did not specify interventions for prevention or treatment, and staff did not consistently follow the care plan directives to offload the resident's heel.
Failure to Consistently Complete Post Dialysis Assessments
Penalty
Summary
The facility failed to ensure consistent completion of post dialysis assessments for a resident with End Stage Renal Disease (ESRD) who received dialysis treatments while residing in the facility. Clinical record review showed that although pre-dialysis assessments were completed, post-dialysis assessments were missing on several occasions, specifically on 5/28/25, 6/6/25, and 6/9/25. The resident's care plan identified the risk for complications related to dialysis, and the facility's policy required ongoing assessment and monitoring before and after dialysis treatments. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that the expected process was to complete both pre and post dialysis assessments and document them in the electronic health record. However, review of the resident's electronic health record revealed that post dialysis assessments were not completed or documented for the specified dates, contrary to facility policy and professional standards of practice.
Facility Assessment Failed to Address Hemodialysis and G-Tube Resident Needs
Penalty
Summary
The facility failed to ensure its Facility Assessment accurately identified and addressed the specialized staff training and supply needs for residents currently receiving hemodialysis and those receiving nutrition, hydration, and medications via a gastrostomy tube (G-tube). A review of the Resident Matrix showed that three residents were receiving hemodialysis and two residents were receiving care through a G-tube, yet the Facility Assessment did not reflect the presence of any such residents or their associated care requirements. None of these residents were new admissions, as all had been admitted more than 30 days prior to the review. During an interview, the Administrator acknowledged that specialized medical and nursing supplies, as well as staff education and training, would be necessary to care for residents with enteral feeding tubes and those receiving dialysis. The facility's policy and the Administrator both indicated that the Facility Assessment should be updated with changes in census case mix or the addition of new services, but the most recent assessment did not include the current needs of residents requiring hemodialysis or enteral feeding. This omission was identified despite the involvement of department heads, leadership, the Medical Director, and other stakeholders in the assessment process.
Failure to Maintain Sanitary and Comfortable Resident Room Environment
Penalty
Summary
A deficiency was identified when a pervasive urine odor was present in a resident's room, compromising the sanitary and comfortable environment required for residents, staff, and the public. Observations on multiple occasions revealed a strong urine odor upon entering the room, with staff interviews confirming that this was a persistent issue. The resident involved had severely impaired cognition, as indicated by a low BIMS score, and was frequently incontinent of urine. The care plan noted the resident's non-compliance with hygiene needs, specifically a refusal to wear incontinence products despite frequent incontinence. Housekeeping staff reported that the resident's bedding was changed daily and the mattress was sprayed, but acknowledged that the odor remained, particularly due to the resident missing the toilet frequently. Wet areas were observed on the bathroom floor, and staff confirmed that floors were mopped daily, but interventions only partially addressed the odor. Facility policy required prompt disposal of soiled linens and reporting of lingering odors, but the persistent urine smell indicated these measures were insufficient in this case.
Failure to Ensure Resident Dignity During Meal Service and Catheter Care
Penalty
Summary
Staff failed to treat residents with dignity in two separate incidents. In the first case, a resident with diagnoses of anxiety, depression, and morbid obesity, and with intact cognition, did not receive a breakfast tray in a timely manner. The resident reported to the nurse that she did not get her breakfast tray after trays were passed, which made her very upset. Staff interviews revealed that the CNA assigned to pass trays was not permitted in the resident's room, and instead of arranging for another staff member to deliver the meal, the resident was left waiting. The Director of Nursing acknowledged that a check-off system should be in place to prevent missed meal trays. In the second incident, a resident with severe cognitive impairment, Alzheimer's disease, multiple sclerosis, and bipolar disorder, who utilized an indwelling catheter, was observed in the dining room on multiple occasions without a dignity cover on the catheter bag. The catheter bag, containing visible dark yellow urine, was exposed in the presence of other residents. Staff interviews confirmed that catheter bag covers were not available in the facility storage, and both nursing staff and the DON stated that covers should be used to promote resident dignity. Facility policy required the promotion and maintenance of resident dignity, including the use of catheter bag covers.
Failure to Complete Self-Medication Administration Assessments
Penalty
Summary
The facility failed to ensure that self-medication administration assessments were completed for two residents who were permitted or requested to self-administer medications. For one resident with diagnoses including heart failure, diabetes, and anxiety disorder, the care plan noted non-compliance with medication administration, and the resident was observed with a cup of medications at bedside, specifically metformin from the previous night. Staff intervened and removed the medication, and review of the electronic health record revealed no documentation of a self-medication administration assessment for this resident. For another resident with multiple diagnoses including multiple sclerosis, paraplegia, seizure disorder, and severe allergies, there was an order for an EpiPen to be kept at bedside for self-administration in case of hypersensitivity reaction. Despite this, the resident reported not having the EpiPen available in the room and staff were unaware of the resident's allergies or the location of the EpiPen. The facility's records showed no completed self-medication administration assessment for this resident, even after the EpiPen was received. Facility policy required an interdisciplinary team determination before allowing self-administration, but this process was not documented for either resident.
Failure to Provide Privacy During Enteral Tube Feeding
Penalty
Summary
Staff failed to provide privacy during an enteral tube feeding procedure for a resident with severe cognitive impairment, hemiplegia, traumatic brain injury, and dysphagia. During the administration of medications and tube feeding via a gastrostomy tube, the LPN left the resident's room door open, exposing the resident's abdomen and G-tube throughout the procedure. A Certified Nursing Assistant also approached the open doorway and communicated with the LPN during the process, while the door remained open. Interviews with nursing staff and the Director of Nursing confirmed that the expectation is for staff to close resident doors and provide privacy during all care and nursing procedures. Review of the facility's policy on promoting and maintaining resident dignity also directed staff to maintain resident privacy. The failure to close the door and provide privacy during the procedure was observed and confirmed as not meeting facility policy and staff expectations.
Failure to Identify and Document Targeted Behaviors for Antipsychotic Use
Penalty
Summary
The facility failed to ensure that targeted behaviors were identified and documented for the use of antipsychotic medication in a resident with severely impaired cognition. The resident, who had a diagnosis of dementia with and without psychotic disturbance, was routinely administered risperidone, an antipsychotic medication. Clinical assessments, including the Minimum Data Set (MDS) and Preadmission Screening, indicated that the resident did not exhibit hallucinations, delusions, or behavioral disturbances, and had not shown behaviors while hospitalized prior to admission. Despite this, the care plan and physician orders referenced the use of antipsychotic medication for symptoms such as mild depression and psychotic features, but did not specify or describe the targeted behaviors that warranted the medication's use. Review of the resident's care plan and interventions revealed a lack of documentation regarding the specific behaviors or symptoms that justified the ongoing use of risperidone. The care plan noted a gradual dose reduction was declined due to continued symptoms, but did not detail what those symptoms were or how the resident's psychotic features manifested. Behavior monitoring records over the past 30 days showed only minimal episodes, such as two instances of anxious/restless behavior and one episode of elopement/exit seeking, with no consistent or significant behavioral issues documented. Interviews with nursing staff and CNAs further confirmed that the resident generally did not display problematic behaviors, with only occasional confusion, minor irritability, or missed toileting events reported. The facility's policy required that psychotropic medications be used only when appropriate to treat a specific, diagnosed, and documented condition, with ongoing monitoring and documentation of the resident's response. However, the documentation for this resident did not meet these requirements, as there was no clear identification or monitoring of targeted behaviors associated with the antipsychotic use. The deficiency was identified through observation, interview, and clinical record review, highlighting a failure to comply with facility policy and regulatory expectations regarding the use of psychotropic medications.
Failure to Timely Report Alleged Abuse and Resident-to-Resident Incidents
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or theft in a timely manner as required by regulatory guidelines for three separate incidents involving multiple residents and a staff member. In the first incident, a resident with severe cognitive impairment and a history of falls was knocked down by another resident in a wheelchair, resulting in a large hematoma to the back of her head and a complaint of headache. Documentation showed that staff had previously observed the resident in the wheelchair behaving unsafely and nearly injuring others, but the care plan lacked sufficient interventions to address this risk. The incident was not reported to authorities prior to the following day, despite staff witnessing the event and suspecting it may have been intentional. In the second incident, a staff member was alleged to have grabbed a resident with severe cognitive impairment by the wrists and pulled her in an aggressive manner, causing the resident distress. The staff member who witnessed the event reported it to a nurse, but the facility had no documentation of this report or evidence that the allegation was reported to the appropriate authorities as of the time of the survey. Interviews with facility leadership confirmed that such allegations should be reported, but there was no record of timely reporting or investigation. A third incident involved a resident with a history of sexually inappropriate behaviors who was witnessed touching another cognitively impaired resident on the shoulders and chest/breast area. Staff immediately separated the residents and assessed them, and the incident was reported to the state agency the following day. However, facility policy required that such allegations be reported immediately, but not later than two hours after the event if abuse or serious bodily injury was involved. The delay in reporting, as well as the lack of timely documentation and investigation in the other incidents, constituted a failure to follow regulatory requirements for reporting suspected abuse, neglect, or theft.
Failure to Ensure Ongoing Discharge Planning and Safe Transfer
Penalty
Summary
The facility failed to ensure an ongoing discharge planning process for a resident with intact cognition who was reviewed for discharge. The resident's care plan indicated no plans for discharge, and the care conference review form left the discharge potential section blank. Although a Notice of Transfer or Discharge form was prepared, it was not signed by the resident or their representative. Progress notes for the period leading up to the proposed discharge date lacked documentation regarding the resident's discharge plan. The resident was later sent to the emergency room for a psychiatric evaluation and subsequently discharged to an inpatient psychiatric facility, with no evidence of a documented discharge plan in the progress notes during this period. Interviews with facility administrators revealed inconsistencies regarding the discharge process, including whether involuntary discharge paperwork was completed and whether the resident received appropriate notifications. The facility's policy required orientation and preparation for transfer or discharge to ensure safety and minimize anxiety, but there was no documentation that these steps were followed. The resident ultimately did not return to the facility, and administrators were unclear about the resident's final placement or the completion of required discharge procedures.
Failure to Revise Care Plans for Significant Changes and Critical Information
Penalty
Summary
The facility failed to revise and update care plans to reflect significant changes and critical information for several residents. For one resident with hemiplegia, dysphagia, and chronic pain syndrome, there was documented significant weight loss over a short period, but the care plan did not address this weight loss or provide direction for intervention, despite facility policy requiring individualized interventions for nutritional risk. The Director of Nursing confirmed that care plans should address significant weight losses and that staff should notify the physician and complete weights as ordered. Another resident with hemiplegia, morbid obesity, and a history of traumatic brain injury was involved in an incident where they propelled their wheelchair into another resident, causing a fall. The care plan included some interventions for wheelchair mobility and spatial awareness, but lacked additional safety interventions to ensure the safety of the resident and others. The DON acknowledged that if staff believed a resident was unsafe in a wheelchair, appropriate interventions should be included in the care plan. Additional deficiencies included a resident whose care plan did not reflect a change in advanced directive status from full code to DNR, despite documentation in nursing notes and family confirmation. Another resident with severe allergies to food, environmental factors, and medications had no care plan focus area or interventions addressing these allergies, nor documentation of a self-medication assessment or the location of their EpiPen, despite orders allowing self-administration. These omissions were contrary to facility policy and best practices for comprehensive, individualized care planning.
Failure to Provide Adequate Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide an adequate number of baths for two residents who were dependent on staff for bathing assistance. One resident, with diagnoses including heart failure, depression, and obesity, was cognitively intact and had a care plan specifying showers on Tuesdays and bed baths on Fridays. Documentation showed missed baths, with gaps of up to ten days between bathing, and instances where refusals were recorded without the resident actually refusing. There was also a lack of follow-up documentation or staff response to missed or allegedly refused baths, despite facility policy requiring notification and follow-up by nursing staff. Another resident, with moderate cognitive impairment, diabetes, recent UTI, Parkinson's disease, dementia, and pressure ulcers, was also dependent on staff for bathing and required two-person assistance. The care plan addressed resistance to care and outlined steps for staff to follow if the resident refused. However, documentation revealed a seven-day gap between showers, coinciding with the scheduled bath aide's vacation, and staff interviews confirmed the resident had not refused showers. Facility policy required regular bathing to maintain hygiene and prevent skin issues, but this was not consistently followed.
Failure to Assess and Intervene for High Blood Sugar Episodes
Penalty
Summary
The facility failed to assess and intervene appropriately for two residents with diabetes who experienced multiple episodes of high blood sugar (hyperglycemia). For one resident with a history of diabetes, hemiplegia, and seizure disorder, the care plan directed staff to observe for signs of hyperglycemia, and the medication order required staff to administer insulin and notify the provider for blood sugars over 399 mg/dl. However, the electronic health record showed several blood sugar readings above this threshold without documentation of provider notification or follow-up interventions. Similarly, another resident with diabetes, heart failure, and anxiety had care plan instructions for monitoring medication effectiveness and orders for insulin administration. Despite blood sugar readings above 400 mg/dl, there were no documented provider notifications or follow-up actions. Staff interviews revealed inconsistent understanding of when to notify providers about high blood sugar levels, and the Director of Nursing acknowledged poor documentation practices and agreed that staff should have contacted the provider for abnormal blood sugars.
Failure to Follow Infection Control and Catheter Care Protocols
Penalty
Summary
Staff failed to follow proper infection control and catheter care procedures for a resident with an indwelling urinary catheter. During observed catheter and perineal care, a CNA used the same side of a washcloth multiple times to clean different areas, did not rinse or dry the resident’s skin after cleaning, and did not perform hand hygiene between glove changes. The CNA also did not consistently use the required Enhanced Barrier Precautions (EBP), such as wearing a gown, during high-contact care activities. Interviews with staff confirmed a lack of adherence to hand hygiene protocols and proper use of personal protective equipment as outlined in facility policy. The resident involved had a history of multiple sclerosis, neurogenic bladder, and a recent urinary tract infection, and was dependent on staff for toileting. The care plan specified the need for EBP due to the presence of an indwelling catheter and a history of multidrug-resistant organism colonization. Despite these documented needs, staff did not consistently implement the required precautions or follow the facility’s catheter care policy, which included specific steps for cleaning, drying, and securing the catheter and surrounding area. Additionally, the resident reported being without an anchoring strap for the catheter tubing, resulting in the tubing being taped to the thigh, which caused irritation and pulling. Observations revealed the catheter bag was leaking and covered with a stained pillowcase, and the bag was not promptly changed after the leak was reported. Staff interviews confirmed that the expected practice was to use proper anchoring devices and to change leaking catheter bags immediately, but these actions were not taken in a timely manner.
Failure to Notify Physician and Intervene After Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician and implement timely interventions following a significant weight loss in a resident with multiple medical conditions, including hemiplegia, dysphagia, and chronic pain syndrome. The resident was dependent on staff for eating assistance and had a feeding tube, with severely impaired cognition. Despite care plan directives and physician orders to monitor weights and notify the provider of significant changes, the facility did not clarify discrepancies in recorded weights, did not document a weight during a required week, and did not notify the physician of a substantial weight loss from 166 lbs to 150 lbs over eight days. There was also no documentation of interventions to address the weight loss prior to eventual physician notification. Staff interviews revealed a lack of clarity regarding which weight measurements were accurate and inconsistent monitoring and follow-up on significant weight changes. The Registered Dietician was on leave during the period in question, and the substitute RD did not monitor or document weight changes as required. The facility's policy required physician notification and individualized care plan interventions for significant weight changes, but these actions were not documented or carried out in a timely manner for the resident.
Failure to Provide Requested Therapy Services
Penalty
Summary
The facility failed to provide specialized rehabilitative therapy services for a resident who expressed a desire to become more mobile. The resident, who had diagnoses including heart failure, diabetes, and anxiety disorder, was found to have intact cognition. Documentation showed that the resident requested physical therapy, but there was no evidence in the clinical record of follow-up or provision of therapy services after the initial request. Staff interviews confirmed that the resident's changing payor source was cited as a challenge, but there was no documentation of further efforts to address the resident's request for therapy. Facility policy required the provision of specialized rehabilitative services to meet residents' needs, but this was not followed in this case.
Failure to Post Daily Nurse Staffing and Census Information
Penalty
Summary
The facility failed to post the daily census and nurse staffing information in a visible location as required by facility policy. Multiple observations conducted on several dates revealed that the required information was not posted in the lobby area, where it was supposed to be accessible to residents, staff, and visitors. The absence of this posting was confirmed during interviews with the Administrator and the Staffing Coordinator. The Administrator acknowledged that the information should have been posted above the sign in/out table and confirmed it was not present during the surveyors' visits. The Staffing Coordinator stated she was not aware that posting the daily census and nurse staffing information was her responsibility prior to the day of the interview. Review of the facility's policy indicated that the nurse staffing sheet should be posted daily at the beginning of each shift and be readily available for review.
Failure to Follow Physician Orders for Warfarin Administration
Penalty
Summary
A deficiency occurred when staff failed to follow physician orders for warfarin (Coumadin) administration for a resident with a history of atrial fibrillation, dementia, and a prosthetic heart valve. The resident had a prescribed warfarin dose of 5.5 mg daily, with a therapeutic INR goal of 2.5 to 3.5. Despite an elevated INR result of 6.7, a physician order was given to hold the warfarin dose and decrease the daily dose to 5.0 mg starting the following day. However, the Medication Administration Record (MAR) documented that the resident continued to receive 5.5 mg of warfarin on the day of the elevated INR and for the next three days. The resident's INR continued to rise, reaching 12.4 on a subsequent test. The resident was then admitted to the hospital with pneumonia, urinary tract infection, and a critically high INR of 13, requiring treatment with Vitamin K. Interviews with staff revealed confusion and lack of clarity regarding the process for holding medications, transcribing physician orders, and updating the MAR. Staff members were unsure about how to properly document and communicate hold orders, and there was inconsistency in the understanding of who was responsible for entering and confirming medication changes in the electronic health record system. The facility's policy required clear documentation and adherence to physician orders for anticoagulant use, including holding medications when lab values were outside the therapeutic range. Despite this, the resident received unnecessary doses of warfarin after orders to hold the medication, resulting in a significant medication error and an Immediate Jeopardy situation for the resident's health and safety.
Removal Plan
- Policy/procedure review/revision by the DON/designee.
- Licensed nurse education on facility policies regarding high-risk medication, anticoagulants, transcribing physician's orders, and notifying the physician when lab values not in the therapeutic range, and re-education on putting in appropriate hold orders.
- Licensed nurse education on appropriate transcription of putting medication on hold.
- Corrective action/one to one education with licensed nurse/Certified Medication Aide identified in deficient practice.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for its residents, as evidenced by observations and interviews with residents and staff. Resident #5, who has an intact cognitive status and requires maximal assistance for daily activities, reported that her room was filthy and not cleaned properly. Observations confirmed that the floor in her room was gritty, the bathroom floor was wet with pooled dark water, and debris was present on the toilet seat and along the backside of the toilet. Staff B, a housekeeper, was observed leaving Resident #5's room without adequately cleaning these areas. Similarly, Resident #3, who has a moderately impaired cognitive status and requires maximal assistance, was found to have a dirty room and unswept, unmopped bathroom floors. Despite Staff B's efforts to clean the room, toilet tissue remained on the floor, indicating incomplete cleaning. Interviews with Staff B and Staff A, the Housekeeper Director, revealed inconsistencies in cleaning practices and a lack of documentation for monthly deep cleaning. Staff A mentioned that each resident's room should be cleaned daily, with beds stripped and sanitized weekly, and deep cleaning performed monthly, but was unable to provide records of these activities.
Failure to Conduct Proper Narcotic Counts and Secure Medication Keys
Penalty
Summary
The facility failed to adhere to its policy requiring two licensed nurses to conduct shift change controlled substance counts, leading to discrepancies in narcotic counts. On one occasion, a Certified Medication Aide, Staff C, completed the narcotic count alone at the end of her shift after being unable to contact the overnight nurse. She then left the medication cart keys in an unlocked drawer at the nurse's station, a practice she stated was common. This lack of adherence to protocol was further evidenced when Staff B, a Certified Nurse Aide, observed another aide, Staff A, with the medication keys and rummaging through the medication cart. Additionally, Staff D, a Registered Nurse, also failed to follow the facility's policy by counting narcotics alone on multiple occasions and passing the medication cart keys without conducting the required count with another nurse. This resulted in missing narcotics, including Hydrocodone/APAP and Morphine sulfate, as discovered by Staff E, a Certified Medication Aide, during her shift. The discrepancies were reported to the Administrator and Director of Nursing, highlighting the facility's failure to maintain accurate narcotic counts and secure medication cart keys as per their policy.
Unauthorized Access to Medication Cart Keys and Missing Narcotics
Penalty
Summary
The facility failed to ensure that medication cart keys were only accessible to authorized personnel, leading to a breach in the security of controlled substances. On the evening of 7/9/24, Staff C, a Certified Medication Aide, was responsible for passing medications and completed the narcotic count with a Registered Nurse, Staff G. However, at the end of her shift, Staff C was unable to find the overnight nurse to complete the narcotic count and instead counted the narcotics on her own, which was a common practice at the facility. She then placed the medication cart keys in an unlocked drawer at the nurse's station, in the presence of two aides, before leaving. This practice was corroborated by Staff B, a Certified Nurse Aide, who witnessed Staff A, another aide, accessing the medication cart with the keys left unsecured. The following morning, Staff E, a Certified Medication Aide, discovered missing narcotics during her shift. She found that two tablets of Hydrocodone/APAP and a dose of Morphine sulfate were missing from the supplies of two residents. Staff E reported these findings to Staff D, the overnight charge nurse, and subsequently to the Administrator and Director of Nursing. Later, during a shift change, Staff E and Staff F, an LPN, discovered an entire bubble pack of 30 doses of Oxycodone was missing from another resident's supply. The report highlights the facility's failure to adhere to its policy requiring two licensed nurses to account for all controlled substances and access keys at the end of each shift, resulting in unauthorized access to medication cart keys and missing narcotics.
Inaccurate MDS Coding for Medications and Services
Penalty
Summary
The facility failed to accurately code medications and services in the Minimum Data Set (MDS) assessments for four residents. Resident #34's MDS inaccurately coded insulin use, as the resident's insulin orders were discontinued, yet the MDS reflected insulin administration. Resident #22's MDS failed to indicate hospice services, despite the resident receiving hospice care and having hospice as the primary payer. The facility's policy on maintaining MDS assessments lacked documentation on ensuring the accuracy of the MDS. Resident #21's MDS inaccurately indicated the use of anticoagulant medication instead of antiplatelet medication, despite physician orders for clopidogrel, an antiplatelet medication. Similarly, Resident #25's MDS incorrectly listed anticoagulant medication use, while the resident was prescribed and administered antiplatelet medications, including clopidogrel and aspirin. These discrepancies highlight the facility's failure to ensure accurate MDS coding, impacting the care and services provided to the residents.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that each resident had a comprehensive individualized care plan that accurately reflected their plan of care. This deficiency was identified for four residents. One resident, with a diagnosis of type 2 diabetes mellitus, had a care plan that lacked specific interventions or a focus area for diabetes management, despite having physician orders for insulin. The Corporate Nurse acknowledged the absence of a diabetes focus in the care plan, which was expected to include monitoring of blood sugars. Another resident, who used oxygen therapy, had a care plan that did not address the use of oxygen, even though physician orders specified oxygen administration to maintain adequate oxygen saturation levels. The facility's Director of Nursing and Corporate Nurse were initially unaware of the omission, attributing it to the resident's hospice services, but later acknowledged the oversight. A third resident, with a diabetic foot ulcer and other wounds, had a care plan that failed to document current wounds or interventions for wound care and monitoring. The care plan also lacked documentation for the monitoring and care of the resident's PICC line and antibiotic administration. The Director of Nursing confirmed the care plan's deficiencies. Additionally, a fourth resident's care plan inaccurately reflected hospice services, lacking a specific focus and interventions related to hospice care, despite the resident's enrollment in hospice services.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide adequate staffing in the dining room during lunch, resulting in insufficient assistance for residents with eating and toileting needs. This deficiency was observed when a Licensed Practical Nurse (LPN) was the only staff member present in the dining room, assisting multiple residents simultaneously. Resident #17, who had severe cognitive impairment and required assistance with toileting, experienced an incontinent episode in the dining room due to the lack of timely help. The LPN attempted to instruct the resident to propel himself to the bathroom, but he was unable to make it in time, leading to the incident. Other residents also reported issues related to insufficient staffing. Resident #33, with moderately impaired cognition, expressed frustration over long wait times for assistance with changing, attributing the delays to a lack of staff. Similarly, Resident #45, who required assistance with various activities, reported receiving incorrect medication and delayed administration of her evening medication, again pointing to inadequate staffing levels. Resident #41, with moderately impaired cognition, noted that it often took a long time for staff to respond to call lights, further highlighting the staffing issues. Interviews with staff members revealed that the facility typically scheduled three Certified Nurse Aides (CNAs) for the hall, but on the day of the incident, only two were available due to one CNA attending an appointment with a resident. Staff members acknowledged that with only two CNAs, they struggled to provide timely care, and residents did not receive the attention they deserved. The Director of Nursing (DON) and the Administrator both commented on the situation, with the DON noting that the facility usually had sufficient staffing and the Administrator attributing the incident to a lack of communication rather than staffing shortages.
Failure to Follow Pureed Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed dietary menu for residents on a pureed diet. During an observation on June 26, 2026, Staff H, a cook, prepared a meal that omitted pureed cornbread, which was specified in the Week 4 Wednesday Diet Spreadsheet. The menu for the pureed diet included pureed barbecue pork, potato salad, creamy coleslaw, cornbread with margarine, cinnamon applesauce, coffee or hot tea, and milk. However, the cornbread was not pureed as required. The facility had a census of 61 residents, with five residents on a pureed diet and one additional resident who requested it. The Dietary Manager acknowledged the oversight, admitting that the cornbread might have been missed. The facility's Food Preparation Guidelines, revised in January 2023, instructed staff to follow written menus and standardized recipes, which were not followed in this instance.
Sanitation and Food Safety Deficiencies in Kitchen and Food Transport
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary manner, as observed during an inspection. Several issues were noted, including bins of cornstarch and sugar with scoops stored inside the product, which is not a sanitary practice. The chest freezer contained two bags of hamburger with openings, exposing the contents to air, and loose tater tots were found in one of the storage compartments. Additionally, loose debris was observed inside the bread refrigerator, and an open, undated container of cultured sour cream was found in Refrigerator 5. The Dietary Manager acknowledged the oversight regarding the sour cream's date and the lack of testing for the dishwasher's temperature and chemical levels, which are essential for ensuring proper sanitation. Furthermore, the facility did not adequately cover food during transportation to residents' rooms. Dietary staff were observed carrying uncovered plates through the hallway to different resident rooms, as the facility lacked lids for the plates. The Dietary Manager admitted that they recommended using foil to cover the food during transportation, but this practice was not consistently followed. These deficiencies highlight lapses in food safety and sanitation practices within the facility, which could potentially impact the quality of care provided to the residents.
Failure to Provide Meal Choices to Resident
Penalty
Summary
The facility failed to provide meal choices to a resident, identified as Resident #58, who had intact cognition and a diagnosis of Stage 4 chronic kidney disease. The resident reported that meals were brought to her without being given a choice, and she was not provided with a menu. Observations confirmed that meals were delivered without prior consultation, and the resident expressed dissatisfaction with the food quality and quantity. Interviews with staff revealed inconsistencies in the process of offering meal choices, with some staff unsure if the resident was asked about her preferences consistently. The Dietary Manager and other staff members acknowledged that while there was an 'always available' menu, the process of collecting meal preferences was not documented, and some residents, including Resident #58, were sometimes missed. The Dietary Manager admitted that the kitchen staff did not always manage to ask all residents about their meal choices, especially if they were not in their rooms. The facility's policy required offering appropriate alternatives, but this was not consistently implemented for Resident #58, leading to the deficiency in honoring the resident's right to self-determination regarding meal choices.
Failure to Notify Ombudsman of Resident Hospitalization
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's hospitalization, which is a requirement for transfers or discharges. The incident involved a resident with moderately impaired cognition, as indicated by a BIMS score of 11. The resident was transferred to the hospital following a provider's new orders and returned to the facility the next day. However, the Notice of Transfer Form to the Long Term Care Ombudsman did not include this hospitalization. The Social Worker explained that she was trained to notify the Ombudsman only if a resident stayed out of the facility overnight, not for shorter durations. The facility's policy required the Social Services Director or designee to provide copies of emergency transfer notices to the Ombudsman, which could be sent on a monthly basis if they met all content requirements.
Failure to Adhere to PASRR Recommendations and Timely Submissions
Penalty
Summary
The facility failed to adhere to the Preadmission Assessment Screening and Resident Review (PASRR) Level II recommendations for two residents, resulting in deficiencies. For Resident #34, the facility did not follow the special recommendation to designate a Power of Attorney (POA) for healthcare and financial matters, as directed by the PASRR Level II outcome. The resident's electronic medical record lacked documentation of a designated POA, despite the PASRR's directive. Interviews with the facility's staff, including the Administrator and the Director of Nursing (DON), revealed a misunderstanding of the PASRR requirements, with the Administrator believing that a POA was only necessary in case of incapacity, despite the resident's intact cognition. Additionally, the facility failed to submit the PASRR Level II in a timely manner for both Resident #2 and Resident #34. Resident #2's PASRR Level I screen was submitted almost a year after the expiration of the prior PASRR approval, which constituted a federal compliance issue. The resident had a history of mental health diagnoses, including anxiety, depression, and PTSD, and required specialized services as identified by the PASRR. The Director of Nursing and the Administrator both acknowledged that the PASRR should not have lapsed, indicating a lapse in the facility's compliance with federal regulations.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure proper medication administration for two residents, leading to deficiencies in professional standards of care. For Resident #33, the facility did not document the administration of medications by the Certified Medication Aide (CMA), Staff I, on the Medication Administration Record (MAR). Instead, the MAR inaccurately reflected that a Licensed Practical Nurse (LPN), Staff K, administered the medications. Observations revealed that Staff I carried the medication cup in her pocket before administering it to Resident #33, which is against the facility's policy. Staff I, who was new to the position, admitted to using another staff member's login to administer medications due to not having her own access yet. For Resident #45, the facility failed to prevent the administration of incorrect medications on multiple occasions. Resident #45 reported receiving the wrong pills four times, and on one occasion, she received medications intended for another resident, Resident #58. The incident was documented in the facility's records, and the nurse involved, Staff N, admitted to leaving the wrong medications in Resident #45's room, which the resident subsequently took. The Director of Nursing (DON) acknowledged the error and stated that the nurse did not follow the medication rights, which include verifying the right resident, medication, time, dose, and route. The facility's Medication Administration Policy, dated September 2023, directs staff to avoid touching medications with bare hands and to sign the MAR after administering medications. The policy also requires verification of the resident's name, medication name, form, dose, route, and time against the MAR. These deficiencies highlight lapses in adherence to the facility's medication administration protocols, resulting in medication errors for the residents involved.
Failure to Follow Bowel Management and Wound Care Protocols
Penalty
Summary
The facility failed to follow up on a resident's bowel movement status and did not administer prescribed medications for constipation. Resident #3, who had moderately impaired cognition and frequent bowel incontinence, did not have a bowel movement from 6/17/24 to 6/23/24. Despite having physician orders for Dulcolax suppository and Milk of Magnesia to be administered as needed for constipation, there was no documentation of these medications being given during this period. The facility's electronic health record system was supposed to alert staff if a resident did not have a bowel movement for three days, prompting the administration of Milk of Magnesia and notifying the doctor if there were no results. However, these steps were not followed, and the facility's bowel management policy was not adhered to. Additionally, the facility failed to adequately assess and document a non-pressure wound for Resident #51, who had a diabetic foot ulcer. The treatment administration record showed orders for wound care on the left heel, but observations and interviews revealed that the wound was actually on the right heel. The Director of Nursing and a Registered Nurse confirmed that Resident #51 never had a wound on the left heel, indicating a discrepancy in the treatment orders and documentation. The facility's wound treatment management policy did not address this issue, leading to inadequate assessment and intervention for the resident's wound care needs.
Resident Injury During Repositioning
Penalty
Summary
The facility failed to prevent an accident involving a resident during repositioning in bed, resulting in the resident's head hitting the bed rail and causing a bruise. The resident, who had Alzheimer's disease with late onset and fragile skin, was being repositioned by a CNA when the incident occurred. The care plan for the resident included instructions to use caution during transfers and bed mobility to prevent injury. Despite these instructions, the resident's head hit the grab bar during repositioning, leading to a bruise on the forehead. Interviews with staff revealed that the resident often resisted repositioning and could be difficult to move, sometimes pushing against the bed or grabbing at staff. On the day of the incident, multiple CNAs were present, and the resident's head hit the grab bar as they were rolled to the side. Staff noted that the resident was positioned too close to the side of the bed, contributing to the accident. The facility's policy on safe resident handling and transfer emphasized the need for safe handling to prevent injury, but this was not effectively implemented in this case.
Failure to Administer Continuous Oxygen Therapy
Penalty
Summary
The facility failed to adhere to the physician's order for continuous oxygen administration for a resident with severe cognitive impairment and multiple health conditions, including ventricular tachycardia, atrial fibrillation, heart failure, cerebrovascular accident, and non-Alzheimer's dementia. The resident was observed multiple times without the prescribed oxygen therapy, despite having an order for continuous administration at 3 liters per minute via nasal cannula. Observations revealed that the resident was in the dining room without oxygen, with the oxygen tank attached to the wheelchair but not connected, and the oxygen concentrator in the room set to a lower level than prescribed. Staff interviews indicated that the resident often did not comply with keeping the oxygen tubing in place, and the Director of Nursing acknowledged the continuous oxygen order due to the resident's congestive heart failure. However, the staff's approach was to ask the resident if they wanted to wear oxygen while eating, rather than ensuring compliance with the physician's order. The facility's policy required licensed nurses and nurse aides to have the necessary competencies and skills to care for residents' needs as identified in their care plans, which was not demonstrated in this case.
Repeat Deficiencies in QAPI Process
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies. These deficiencies were identified during the facility's current recertification and complaint survey, as well as in surveys completed over the last fifteen months. The deficiencies included issues with Minimum Data Set (MDS) accuracy, care plan timing and revision, professional standards, respiratory care, and being free from accident hazards. Additionally, there were citations for assessment and intervention, insufficient staffing, and food procurement and sanitation. The facility's QAPI policy, dated April 2022, outlined a process for developing and implementing plans of action to correct identified quality deficiencies. However, the facility continued to receive citations for similar issues across multiple surveys. Interviews with the Administrator and Corporate Nurse revealed that the facility kept processes in Quality Assurance until they met substantial compliance, typically between 3 to 6 months, and updated processes when they did not work. Despite these efforts, the facility continued to receive repeat citations, indicating a failure to effectively address and correct the underlying causes of the deficiencies.
Food Temperature and Hygiene Deficiencies
Penalty
Summary
The facility failed to serve mandarin oranges at the appropriate temperature, serve room trays at the appropriate temperature, and maintain proper hygiene practices during food handling. During an observation, the cook checked the temperatures of the lunch food prior to service and found that the mandarin oranges were at 42 degrees Fahrenheit, which is above the required temperature of 41 degrees Fahrenheit or lower for cold foods. Additionally, the post-meal service temperatures showed that the mandarin oranges had risen to 51 degrees Fahrenheit. The test tray temperatures at the end of the hall also revealed that the mandarin oranges were at 50 degrees Fahrenheit, and the hot foods were below the required 135 degrees Fahrenheit for hot foods, with the pork loin at 127.4 degrees Fahrenheit, broccoli at 125.3 degrees Fahrenheit, and potatoes at 107.4 degrees Fahrenheit. During the lunch meal service, the cook, identified as Staff A, was observed using her gloved hand to move food items on the plates without changing gloves or washing hands afterward. Specifically, Staff A used her gloved hand to move broccoli, potatoes, and pork loin on the plates and did not remove the gloves or wash her hands after handling the food. This practice was acknowledged by Staff A, who stated that she should have used tongs and should have removed her gloves and washed her hands after touching the food on the plate. Interviews with the Dietary Manager and the Dietician revealed concerns about the food temperatures and hygiene practices. The Dietary Manager acknowledged the issue with the temperatures at the end of the hall and stated that Staff A should have used a spatula or changed her gloves and washed her hands. The Dietician emphasized the need for education and review of the temperatures and proper food handling practices to avoid the risk of foodborne illness. The facility's guidelines and procedures for proper hand washing, glove use, and monitoring food temperatures were not followed, leading to the identified deficiencies.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood glucose levels exceeded 450 mg/dl for one of the three residents reviewed. Resident #4, who has a diagnosis of Type II diabetes mellitus and receives insulin daily, had multiple instances of elevated blood glucose levels recorded in the Electronic Medical Record (EMR) without corresponding documentation that the physician was notified. Specific instances included blood glucose readings of 458 mg/dl, 544 mg/dl, 463 mg/dl, 512 mg/dl, and 558 mg/dl on various dates. Despite the facility's policy requiring notification of the physician for blood glucose levels over 450 mg/dl, there was no documentation in the Progress Notes indicating that the physician was informed of these elevated readings. Interviews with staff, including a Registered Nurse (RN), the Director of Nursing (DON), and the Administrator, confirmed that the protocol was to notify the physician of elevated blood glucose levels. However, it was revealed that the staff often got busy and did not always document the notifications. The DON and Administrator acknowledged that while the Certified Medication Aides (CMAs) reported the blood glucose levels to the nurses, the nurses did not consistently chart the notifications to the physician. The facility's policy on Blood Glucose Monitoring emphasized the importance of timely reporting and documentation of critical test results, which was not adhered to in this case.
Failure to Timely Respond to Call Light
Penalty
Summary
The facility failed to answer a call light in less than 15 minutes for a resident with cerebral palsy who required partial/moderate assistance with toileting hygiene and toilet transferring. The resident, who had an intact cognition as indicated by a BIMS score of 13 out of 15, was observed with her call light on for an extended period. Despite the facility's policy requiring prompt response to call lights, the resident waited for approximately 48 minutes before staff responded. During this time, the resident had to clean herself up and resorted to banging a potty chair on the floor to get attention. Interviews with staff revealed inconsistencies in their understanding of the required response time for call lights, with responses ranging from 5 to 15 minutes. The Director of Nursing acknowledged that call lights should be answered within 15 minutes but noted exceptions when multiple lights were on. The facility's policy stated that all staff members who see or hear an activated call light are responsible for responding, and if unable to provide the required assistance, they should notify the appropriate personnel. However, this policy was not adhered to in the case of the resident, leading to a significant delay in providing necessary assistance.
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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