Rotary Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Eagle Grove, Iowa.
- Location
- 500 South Blaine Avenue, Eagle Grove, Iowa 50533
- CMS Provider Number
- 165500
- Inspections on file
- 24
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Rotary Senior Living during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of stroke was on warfarin when providers added antibiotics known to affect INR, but staff did not obtain an INR order, did not have an internal INR tracking process, and relied on the pharmacist and the resident’s spouse for interaction alerts and INR checks. After staff discovered a large bruise in the groin area while the resident was on warfarin and antibiotics, they documented it but did not complete a skin sheet, investigation, or increased monitoring, and TAR entries failed to reflect the bruise or anticoagulant side effects. Two days later, the resident’s spouse obtained an INR of 7.3 and notified staff, who then contacted the anticoagulation clinic and received instructions to hold warfarin and give vitamin K or spinach, but the resident’s condition deteriorated before these could be implemented, leading to hospital transfer where an INR >13 and a large rectus sheath hematoma with hemoperitoneum were found. Surveyors concluded that the facility failed to adequately monitor and manage high-risk anticoagulant therapy and associated bruising and drug interactions, resulting in an Immediate Jeopardy deficiency.
A resident with severe cognitive impairment, dementia, polyneuropathy, and significant ADL dependence was found with marked swelling of the left hand, later confirmed by X-ray as an acute nondisplaced fracture of the middle finger. Nursing staff documented the edema, notified the physician, and obtained an X-ray, but no staff witnessed any incident causing the injury, and interviews only produced speculative explanations such as the resident twisting fingers or catching them on side rails. The facility completed only a brief, undated investigation and, despite its policy requiring all injuries of unknown origin to be reported to the state agency within 2 hours, the Administrator determined the event was not reportable, resulting in a failure to report and thoroughly investigate an injury of unknown origin.
A resident with intact cognition and multiple medical diagnoses, including diabetes and a non-pressure skin ulcer, had a care plan and facility policy requiring weekly documentation of skin injury locations and measurements. Over several weeks, staff recorded skin tears, abrasions, bruising, and scratches on the resident’s toes, feet, and arms, but repeatedly failed to include required measurements and precise locations on the Skin Observation Tools. The resident was observed with both feet resting against the bed footboard and reported that this caused sores on the bottom of the right foot and toes. Only later entries included measurements for a right toe and right lateral foot skin tear, and the DON acknowledged that the record lacked complete documentation of the locations and sizes of the skin areas, contrary to the facility’s weekly skin assessment process.
A resident with a history of stroke and hemiplegia required skin checks before and after applying an ankle-foot orthosis (AFO), but the LTC facility failed to document these checks. As a result, a wound on the resident's shin went unnoticed until a dermatology appointment, where it was found to be infected with MRSA. The facility also did not document required weekly skin assessments, leading to the oversight of the resident's wound and subsequent infection.
A resident with severe memory impairments and dementia was not treated with respect and dignity during care, leading to physical aggression. The resident required substantial assistance with daily activities and had a care plan to manage potential aggression. During an evening care session, a CNA acted roughly, causing the resident to become aggressive. The incident was not documented, and an internal investigation was initiated. Other residents and staff reported feeling safe and respected, but the facility's policy emphasizes the importance of dignity and respect for all residents.
A facility failed to report an alleged incident of mistreatment involving a resident with dementia to the Department of Inspection and Appeals within the required 2-hour timeframe. The incident involved a CNA acting roughly during care, leading to the resident's physical aggression. The facility's policy mandates reporting such allegations within 2 hours, but this was not adhered to.
A resident with moderately impaired cognition was served a mechanical soft diet instead of the ordered pureed diet due to a lack of proper documentation and communication among staff. A trial of the pureed diet was conducted without obtaining a formal order, leading to confusion about the correct diet. The DON changed the diet order without assessing the trial's outcome, contributing to the discrepancy.
The facility did not provide the mandated 8 hours of RN coverage on a particular day, as the DON, who was scheduled, did not work. The nursing schedule lacked documentation of RN coverage, and the Administrator confirmed this deficiency. The facility's policy requires daily 8-hour RN coverage to ensure resident health and safety.
The facility did not notify the LTCO of a resident's discharge to the hospital, as required by federal regulation. The clinical record lacked documentation of this notification, and the facility's policy mandates that emergency transfer notices be sent to the LTCO monthly. The Administrator confirmed the absence of documentation and acknowledged the expectation to notify the LTCO.
A facility failed to notify a resident or their representative of the bed hold policy during a hospitalization. The resident's clinical record lacked documentation of this notification, despite the facility's policy requiring it upon admission and when hospitalization is confirmed. The Administrator confirmed the absence of documentation and the expectation for notification.
The facility failed to notify two residents of changes in their Medicare benefit coverage by not providing the Notice of Medicare Non-Coverage (NOMNC) when their Medicare Part A services were ending. The Administrator acknowledged that the NOMNC was not issued because the Social Services Designee did not realize the need to fill out two forms, leading to the omission.
The facility staff failed to perform scheduled controlled medication shift counts and did not destroy a discontinued narcotic medication for a resident with severe cognitive impairment. The medication card and narcotic sheet were left in the narcotic box, and subsequent counts were not performed as required by policy. When the medication was re-ordered, it was discovered missing, prompting an investigation.
Failure to Monitor Warfarin Therapy and Respond to Bruising and Drug Interactions
Penalty
Summary
Facility staff failed to ensure appropriate monitoring and management of anticoagulant therapy for a resident on warfarin whose regimen was affected by additional medications. The resident had a history of stroke, severe cognitive impairment, limited range of motion, and was care planned for anticoagulant therapy with goals to avoid discomfort or adverse reactions. The care plan directed staff to check INR per physician orders and to monitor, document, and report adverse reactions such as bruising and changes in mental status, but it did not include instructions on how to monitor INR or address interactions between warfarin and antibiotics. The January MAR showed warfarin administration and new orders for Rocephin and metronidazole, both of which can affect INR, yet there was no corresponding INR order on the MAR or TAR. On the morning after the physician ordered antibiotics, nursing staff discovered a large 7 cm by 5 cm bruise on the resident’s mons pubis/penis area while the resident was on warfarin and antibiotics. Staff documented the bruise in a nursing note and faxed a note to the physician, but there was no documented follow-up assessment, no skin sheet, no photograph, and no initiation of increased monitoring specific to the bruise or potential anticoagulant side effects. The TAR, which required staff to document monitoring for signs of anticoagulant adverse effects, showed an entry of “N” (no symptoms) on the day the bruise was found and no documentation at all the following day, despite the presence of the bruise. Staff interviews revealed that some nurses and CNAs saw or were told about the bruise, but they did not notify the physician or the resident’s wife in a timely manner, did not complete an investigation for an injury of unknown source, and did not obtain an INR when the bruise was first identified. The resident’s INR was instead checked by his wife two days after staff discovered the bruise, revealing a markedly elevated INR of 7.3, which she reported to staff. Nursing staff then contacted the anticoagulation clinic, received recommendations to hold warfarin and administer vitamin K or spinach, and were informed that Rocephin, metronidazole, and the recent illness could severely affect INR levels. Before staff could implement these orders, the resident’s condition deteriorated, with documented lethargy, inability to follow commands, drooling, and abnormal lung sounds, leading to transfer to the hospital where an INR greater than 13 and a large rectus sheath hematoma with hemoperitoneum were identified. Throughout this period, facility staff reported they relied on the pharmacist to notify them of drug interactions and did not have a standard expectation or standing orders for more frequent INR checks when residents on warfarin started antibiotics. The DON acknowledged that staff failed to investigate the bruise as a potential injury of unknown source and that there was no standing process for INR monitoring frequency when high-risk medications such as antibiotics were added to warfarin therapy. Surveyors determined that these failures constituted a deficiency in ensuring the resident’s drug regimen was free from unnecessary drugs, specifically by not adequately monitoring the INR and not responding appropriately to signs of possible anticoagulant-related bleeding while the resident was receiving interacting medications. The Department of Inspections, Appeals, and Licensing determined that the situation rose to the level of Immediate Jeopardy beginning when staff failed to implement increased monitoring after discovering the bruise while the resident was on medications that increased bleeding risk. The facility census included multiple residents on blood-thinning medications, and staff interviews showed inconsistent understanding of monitoring requirements for warfarin compared to newer anticoagulants, as well as reliance on the resident’s wife and the anticoagulation clinic for INR management without an internal tracking or standardized monitoring process.
Failure to Report and Adequately Investigate Finger Fracture of Unknown Origin
Penalty
Summary
The facility failed to timely report an alleged violation involving mistreatment, neglect, or injury of unknown origin to the Iowa Department of Inspections and Appeals and Licensing (DIAL) after a resident was found to have a left middle finger fracture. The resident had severe cognitive impairment with a BIMS score of 3, diagnoses including non-Alzheimer’s dementia, polyneuropathy, and macular degeneration, and required substantial to maximal assistance with all ADLs and two staff with a full-body mechanical lift for transfers. The care plan directed staff to protect the resident’s arms with long sleeves, use pillows to prevent bumping arms and feet, and observe and report changes to the physician as needed. On one morning, staff notified the nurse that the resident’s left hand was significantly swollen. The nurse documented non-pitting edema of the left hand without pain on touch, removed the arm protector due to circulatory restriction, and elevated the arm on a pillow. Later that night, the nurse faxed the physician about the significant edema, noting no pain with movement and no edema elsewhere, and received an order to elevate the arm above heart level and a question about obtaining an X-ray. An X-ray obtained the next day showed an acute nondisplaced fracture of the third middle phalanx of the left hand. Nursing documentation reflected that the resident did not cooperate during splint application to the fractured finger. Despite the confirmed fracture and the lack of a witnessed cause, the facility did not report the injury of unknown origin to DIAL within 2 hours as required by its abuse prevention, identification, investigation, and reporting policy. The facility’s investigation consisted of a brief, undated, one-page document stating that no staff witnessed an incident and that the resident frequently rubbed his fingers together, put his hands in his shirt, and had degenerative changes on X-ray. Staff interviews indicated they did not know how the fracture occurred and suggested possibilities such as the resident twisting his own fingers or getting a finger caught in side rails, but no definitive cause was identified. The Interim DON acknowledged that a more thorough investigation should have been conducted, while the Administrator concluded the fracture did not meet criteria for reporting, resulting in the failure to report an injury of unknown origin as required by facility policy.
Failure to Consistently Document Weekly Skin Locations and Measurements
Penalty
Summary
The deficiency involves the facility’s failure to document weekly skin locations and measurements for a resident with identified skin impairments, as required by the care plan and facility policy. The resident had no cognitive impairment, could communicate effectively, and had diagnoses including hypertension, diabetes mellitus, pneumonia, and a non-pressure skin ulcer. The care plan for actual/potential skin impairment, initiated on 10/15/25, directed staff to monitor and document the location, size, and treatment of skin injuries and to complete weekly treatment documentation including measurements (length, width, depth, tissue type, exudate, and notable changes). Multiple Skin Observation Tools documented skin tears and abrasions on the resident’s toes, right foot, and other areas, but repeatedly lacked required measurements and specific locations. For example, a 1/25/26 entry noted skin tears on the left and right toes without measurements, and subsequent entries on 1/28/26, 2/4/26, and 2/11/26 described bruising, scratches, abrasions, and skin tears but did not include measurements or precise locations. The resident was observed on more than one occasion lying in bed with the bottoms of both feet resting against the bed’s footboard, and the resident reported that resting his feet against the footboard caused sores on the bottom of his right foot and toes. A later Skin Observation Tool on 2/25/26 documented a right toe skin tear with measurements and noted scabs on the bottom and side of the right 5th digit, and a 3/2/26 Skin Issues Note recorded a right lateral foot skin tear with specific dimensions, acquired in-house with an unknown onset. Despite these later measurements, the DON acknowledged that the clinical record lacked documentation of the locations and sizes of the areas on the bottom of the resident’s right foot, and stated that nursing staff were expected to follow the facility’s Weekly Skin Assessment and Documentation Process policy, which required weekly documentation and separate assessments for each skin/wound alteration. This failure to consistently document weekly skin locations and measurements for the resident’s skin impairments constituted the cited deficiency.
Failure to Document Skin Checks Leads to Undetected Wound Infection
Penalty
Summary
The facility failed to provide necessary services in accordance with professional standards for a resident with a wound. The resident, who had a history of hypertension, stroke, hemiplegia, hemiparesis, anxiety, and depression, required dependent assistance for activities of daily living and wore an ankle-foot orthosis (AFO) on the right foot. The care plan directed staff to inspect the resident's skin before and after applying the AFO, but the facility did not document these skin checks. As a result, a wound on the resident's right shin went unidentified until a dermatology appointment, where it was discovered to be infected with Methicillin-resistant Staphylococcus aureus (MRSA). The resident's care plan also required weekly skin inspections, but the facility failed to document these assessments. The resident's Minimum Data Set (MDS) assessment indicated no skin issues, yet the dermatology clinic identified a wound during a routine appointment. The clinic took a sample of the wound, ordered an antibiotic, and cultured the drainage, which revealed MRSA. The facility's records lacked documentation of completed skin assessments after removing or applying the AFO, both before and after the infection was identified. Interviews with staff, including Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs), confirmed the absence of documentation for skin checks related to the AFO. The Director of Nursing also verified the lack of documentation for these checks. The facility's Weekly Skin Assessment Policy required comprehensive skin assessments weekly and additional assessments based on changes in the resident's condition, but these were not conducted or documented as required, leading to the oversight of the resident's wound and subsequent infection.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to treat a resident with respect and dignity, which compromised the resident's quality of life. The resident, who had severe memory impairments and was diagnosed with Alzheimer's disease and non-Alzheimer's dementia, displayed physical behaviors such as hitting, kicking, scratching, and grabbing towards others. The resident required substantial to maximal assistance with all activities of daily living, including ambulation. The care plan for the resident indicated that he could become aggressive and combative during care, and staff were instructed to approach him calmly and have assistance present during his care. On one occasion, two CNAs were involved in providing evening care to the resident. Staff A reported that Staff B acted very rough during the process of undressing and completing peri-care for the resident, which led to the resident becoming physically aggressive. Staff A attempted to comfort the resident by placing a hand gently on his shoulder, but the resident continued to exhibit physical aggression, a common behavior associated with his dementia. The incident was not documented in the clinical record, and the facility's internal investigation was initiated after the report was made. Interviews with other residents and staff indicated that they felt safe and treated with respect and dignity, with no concerns about their care. Staff members who worked closely with Staff B described them as helpful and attentive, with no concerns about the quality of care provided. However, the facility's policy and procedure emphasized the importance of treating all residents with dignity and respect, and the incident involving the rough handling of the resident during care was a clear violation of these standards.
Failure to Timely Report Alleged Mistreatment
Penalty
Summary
The facility failed to report an alleged incident of mistreatment involving a resident to the Department of Inspection and Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with severe memory impairments and a history of physical aggression due to Alzheimer's disease and dementia. During an evening care session, a Certified Nurse Aide (CNA) was reported to have acted roughly while assisting the resident, which led to the resident becoming physically aggressive. This incident was reported by another CNA, but the facility did not notify DIAL promptly as required by their policy. The resident's clinical record did not document the incident, and the facility's Administrator confirmed the failure to report within the specified timeframe. The facility's policy, dated May 2023, mandates that all allegations of resident abuse be reported to the Iowa Department of Inspections and Appeals no later than 2 hours after the allegation is made. This deficiency highlights a lapse in the facility's adherence to its own abuse prevention and reporting policies.
Dietary Order Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that the dietary orders for a resident were accurately followed, leading to a discrepancy in the diet provided. Resident #11, who had moderately impaired cognition and was independent in eating, was observed being served a mechanical soft textured diet during a meal observation. However, the physician's order indicated that the resident was supposed to receive a pureed textured diet. This discrepancy arose after a nursing trial of the pureed diet was conducted without proper documentation or confirmation of the correct diet order. The confusion regarding Resident #11's diet order was evident among the staff. Staff A, who served the meal, and the Certified Dietary Manager (CDM) both believed the resident's order was for a mechanical soft diet. The CDM mentioned that a trial of pureed food was conducted due to the resident's stroke, but it was decided to continue with the mechanical soft diet as the resident performed better with it. Staff B, an LPN, confirmed that there was no official order for the pureed diet and that the trial was based on nursing judgment. The Director of Nursing (DON) later obtained a doctor's order for the pureed diet without assessing the trial's outcome, leading to the order discrepancy. The facility's policy on assessment and reassessment of changes in condition was not adhered to, as there was a lack of documentation and communication regarding the trial and subsequent diet order. The DON admitted to changing the diet order without proper assessment, which contributed to the confusion. The policy required comprehensive assessment and documentation to ensure continuity of care, which was not followed in this case, resulting in the deficiency.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage on a specific day, as mandated by regulations. The nursing schedule for that day lacked documentation of RN coverage, and the Director of Nursing (DON), who was scheduled to work, did not fulfill their shift. This deficiency was confirmed during an interview with the Administrator, who acknowledged the absence of the required RN coverage. The facility's policy, updated in March 2021, clearly states the necessity for 8-hour RN coverage daily to ensure resident health and safety, which was not adhered to on the day in question.
Failure to Notify LTCO of Resident Hospitalization
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman (LTCO) of a discharge/transfer to the hospital for a resident reviewed for hospitalization. The clinical record review showed that the resident was discharged from the facility to the hospital and returned a week later. However, the clinical record lacked documentation of LTCO notification regarding this discharge, as required by federal regulation. The facility's policy stated that copies of notices for emergency transfers must be sent to the Office of the State LTCO on a monthly basis. During an interview, the Administrator admitted they could not locate documentation of the LTCO notification for the resident's hospitalization, acknowledging that it is expected to notify the LTCO when a resident is discharged to the hospital.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident or their representative of the bed hold policy during a hospitalization event. Specifically, the clinical record of a resident who was discharged to a hospital and later returned to the facility lacked documentation indicating that the resident or their representative was informed of the facility's bed hold policy. The facility's policy, revised in 2015, mandates that the bed hold policy be presented to residents or their responsible parties upon admission and again when hospitalization or therapeutic leave is confirmed. During an interview, the Administrator acknowledged the absence of the required documentation for the resident's hospitalization period and confirmed the expectation that such notification should occur.
Failure to Provide Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to notify two residents of changes in their Medicare benefit coverage. Specifically, the facility did not provide the Notice of Medicare Non-Coverage (NOMNC) to two residents who were receiving Medicare Part A services, which were ending. During the survey, the facility was unable to produce the NOMNC for these residents when requested. The Administrator acknowledged that the NOMNC was not issued because the Social Services Designee (SSD) did not realize the need to fill out two forms, resulting in the omission of the NOMNC for these residents.
Failure to Perform Narcotic Counts and Destroy Discontinued Medication
Penalty
Summary
The facility staff failed to perform scheduled controlled medication shift counts as directed by facility policy and did not destroy a discontinued narcotic medication for one resident. Resident #1, who had severe cognitive impairment and multiple diagnoses including arthritis, osteoporosis, recent hip fracture, Alzheimer's dementia, and anxiety, had an order for Oxycodone 5 mg to be given as needed for pain. The medication was discontinued by the primary care physician, but the staff did not destroy the remaining medication as required by the facility's policy. Instead, the medication card and narcotic sheet were left in the narcotic box and binder. Subsequently, the staff failed to perform the required narcotic counts at the end of their shifts on two occasions. When the resident complained of hip pain, the physician re-ordered the Oxycodone, but the staff discovered that the medication card and narcotic sheet were missing. The incident was reported to the Director of Nursing and the Administrator, who initiated an investigation. The facility's policy mandates that narcotic counts be completed by two employees within 60 minutes prior to the end of each shift and that any discrepancies be reported immediately.
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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