Royal Oaks Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Urbandale, Iowa.
- Location
- 4614 Nw 84th Street, Urbandale, Iowa 50322
- CMS Provider Number
- 165580
- Inspections on file
- 33
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Royal Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with dementia, significant weight loss, and high ADL dependence did not receive consistent assistance with eating or ordered nutritional supplements. Observations showed one resident repeatedly seated in the dining room with mechanically altered meals and beverages left untouched for extended periods without staff feeding help, despite a care plan requiring one‑person assist, monitoring for dysphagia, and provision of shakes and supplements. Another resident on a puree diet with severe cognitive impairment and documented significant weight loss was left with pureed meals in front of her without timely supervision or touch assistance, even though her care plan called for set‑up/assist and serving supplements per orders. MAR/TAR records lacked documentation that recommended shakes were ordered or provided, and staff interviews confirmed that CNAs were expected to be present in the dining room to assist with feeding and to serve supplements as ordered.
Two residents with multiple pressure ulcers and other wounds did not consistently receive and/or have documented the ordered wound treatments, and proper infection control was not maintained during wound care. For one resident with severe cognitive impairment and multiple unstageable pressure ulcers, physician-ordered treatments to the heel, coccyx, sacrum, and buttocks were repeatedly not signed out as completed on the TAR over many days, despite a care plan directing staff to administer treatments as ordered. For another resident with diabetes, renal insufficiency, spina bifida, an indwelling catheter, and advanced pressure ulcers, an LPN failed to disinfect scissors between dirty and clean tasks, did not change gloves between cleansing a wound and handling new dressings, and removed a dressing from a necrotic foot wound without cleansing or redressing it during the observation. Review of orders and TARs for this resident also showed multiple missing entries for ordered treatments to the heel, foot, and leg/thigh wounds, contrary to facility policies requiring accurate administration and documentation of topical treatments and wound care.
Surveyors found that the facility failed to obtain physician orders for an indwelling urinary catheter for a resident who returned from the hospital with a Foley in place and whose care plan did not reflect the catheter, and also failed to maintain proper catheter infection-control practices for two residents. One resident with complex urologic conditions and a history of UTI with sepsis had a catheter documented as changed on a date that conflicted with CT findings, and was observed with the catheter bag lying on the floor after transfer. Another fully dependent, cognitively impaired resident had Foley tubing lying on the floor and the bag visible from the open doorway for an extended period while multiple CNAs, an RN/ADON, and an LPN passed by or entered the room without correcting it, despite facility policy requiring catheter tubing and drainage bags to be kept off the floor.
The facility failed to prevent significant medication errors by allowing residents without self-administration orders to take medications on their own and by preparing and passing medications to multiple residents at the same time. One resident with intact cognition was found with pills left at the bedside and reported that staff routinely left medications for self-administration without observation. Another cognitively intact resident with anemia, HTN, heart failure, renal insufficiency, and seizure disorder received a roommate’s medications after an LPN prepared and delivered both residents’ medications simultaneously and did not observe ingestion, resulting in the resident consuming Simvastatin, Gabapentin, and oxybutynin in error and experiencing documented changes in mental status, thirst, and sleepiness. Staff interviews and facility policy confirmed that these practices violated established requirements to administer medications to one resident at a time, verify identity, observe ingestion, and avoid leaving medications at the bedside without a self-administration order.
Staff failed to follow the facility’s infection prevention and control requirements for multiple residents, including those on Enhanced Barrier Precautions and transmission-based precautions. A resident with a UTI, bacteremia, and an indwelling catheter, who had an order for EBP with gown and gloves during high-contact care, was transferred by a CNA without any PPE, and the catheter drainage bag was observed lying on the floor. Two other residents on droplet and isolation precautions for Parainfluenza virus and C. difficile had their doors left open, and a CNA entered both rooms without PPE, stating he did not know the precautions or door requirements. Another resident with MS, neurogenic bladder, a suprapubic catheter, and total dependence for ADLs had incontinence and catheter care performed by a CMA/CNA who wore gloves but did not don a gown, despite care plan and physician orders requiring gown and gloves for EBP during peri care, toileting, and catheter/device care.
Two residents with indwelling urinary catheters did not receive care and monitoring as ordered, including incomplete documentation of catheter care, frequent failures to record urine output per shift, and missed doses of prescribed antibiotics for UTI treatment. One resident’s care plan lacked specific catheter-care frequency despite an order for catheter care every shift, and TARs showed multiple days without documented catheter care or urine output. Pharmacy records and MAR review confirmed that a full ordered course of Amoxicillin was never dispensed or administered, and staff interviews revealed inconsistent medication reordering practices, limited use of the E‑kit, and reports that some staff were told not to document when medications were unavailable. These combined failures led to a resident not receiving the full antibiotic course for a UTI and being hospitalized.
Surveyors found persistent pungent odors on two nursing units, especially near a shower room, environmental services area, and an East hallway, with odors recurring over multiple days despite intermittent deodorizing efforts. Staff acknowledged the odors as a daily issue, with the housekeeping director citing possible links to resident personal habits and the maintenance assistant suspecting carpets as a source, while an uncovered trash and linen cart with soiled items was observed contributing to odors. The administrator confirmed the building-wide odor problem, which conflicted with facility policy requiring a homelike environment with pleasant, neutral scents and minimal institutional odors.
Staff failed to follow infection prevention and control practices related to insulin administration, catheter care, and hand hygiene. An LPN reused multi-dose insulin pens from discharged and other residents, contrary to policy requiring pens to be single-resident use and clearly labeled, and administered insulin to cognitively intact residents without an insulin-focused care plan for one of them. CNAs providing care to residents on Enhanced Barrier Precautions did not perform hand hygiene before, during, or after care, did not change gloves between dirty and clean tasks, placed a urine graduate directly on the floor without a barrier, handled the catheter system and room surfaces with contaminated gloves, and did not properly clean or store the graduate, all in violation of facility policies on infection control, catheter care, PPE, and hand hygiene.
A resident with intact cognition and multiple chronic conditions, including A-fib, diabetes, and HTN, was care planned as resistive to care and known to refuse medications, but was not care planned or ordered to self-administer meds. The MAR directed staff to administer three mid-morning pills, and facility policy allowed self-administration only with physician and IDT determination. A CMA placed the medications at the bedside, briefly conversed with the resident, and left the room without administering or confirming ingestion, leaving the meds unattended. The DON and CMAs reported that residents are not permitted to keep meds in their rooms and that staff are expected to remain with residents during administration, while the resident reported that staff periodically leave medications in the room. Facility policy required safe administration as prescribed and restricted self-administration to residents formally assessed and approved to do so.
A resident with atrial fibrillation and other psychiatric and medical diagnoses was discharged from a hospital with a physician order for a 2‑week cardiac event monitor and follow‑up. The LTC facility did not incorporate the monitor into the care plan, and although an order was entered to check the monitor every shift and mail it back, there was no MAR/TAR documentation that monitoring occurred. Staff interviews showed confusion and poor recall about when the monitor was applied, how long it was worn, and who removed it, with reports that it was left on the floor and later reapplied. The facility had no process or policy for tracking or mailing medical devices, and the DON ultimately dropped the boxed monitor in a post office mailbox without knowing it was required to be returned via UPS. The hospital clinic confirmed they never received the monitor or data and were still waiting for results, demonstrating that the facility failed to follow physician orders and professional standards for managing and returning the heart monitor.
The facility failed to consistently offer and provide scheduled showers or baths to multiple cognitively intact residents who were dependent on staff for bathing and had care plans and bath schedules specifying twice‑weekly bathing. One resident with arthritis, chronic pain syndrome, and heart failure reported going more than two weeks between showers, and documentation for two months showed baths recorded on only a minority of scheduled days with no indication whether the remaining scheduled baths were completed, not offered, or refused. Another resident admitted with osteoporosis and major depressive disorder did not receive a first shower for 19 days after admission and then received only two showers over about a month, as confirmed by shower logs and family report. A third resident with pain and impaired mobility had baths scheduled twice weekly, but bath records over three months showed baths documented on only a few of the scheduled days, with one refusal and one hospitalization noted. Staff interviews revealed that CNAs were responsible for baths, relied on room‑based bath lists, and were expected to complete both paper and electronic documentation, but paper bath sheets were often not completed, despite a facility policy requiring assistance with ADLs, including bathing, for residents unable to perform them independently.
A resident with multiple comorbidities, dependence for all care, a history of stroke, and recurrent unwitnessed falls had care plan interventions for neuro-checks after falls and routine full-body skin inspections. Over several months, the resident experienced numerous unwitnessed falls, but neuro-checks were only initiated for some of these events, and many of the completed neuro-check forms were missing required assessment intervals. Full-body skin assessments, previously done regularly, were not documented for an extended period, with only focused diabetic foot evaluations recorded. Documented injuries, including facial bruising, a bruised and torn elbow after a fall, and hand cuts from fingernails, were not subsequently tracked in progress notes or skin assessments, despite staff expectations and facility policy that such assessments and documentation occur.
A nurse left the facility unexpectedly during the night shift, leaving only one nurse on duty who did not assume responsibility for two units. As a result, several residents did not receive scheduled or as-needed medications, including pain management and emergency allergy treatment. One resident experienced severe pain and called 911, while another with a history of anaphylaxis had to self-administer her own epi pen. Staff interviews revealed confusion and lack of action to ensure resident care during this period.
A resident who experienced a fall did not receive documented follow-up assessments, including pain, vital signs, or neurological checks, as required by protocol. The incident was not reported, and necessary documentation was not completed by the nurse on duty, resulting in a lack of post-fall monitoring.
The facility did not maintain complete medical records for three residents who experienced falls, including missing neurological check sheets and incident reports. In one case, neurological monitoring was documented as initiated but the records were lost; in another, an incident report was never completed after a nurse left her position abruptly. These lapses resulted in incomplete documentation of resident care following falls.
A resident suffered two fractures and increased pain after being left unsupported during a transfer without a gait belt or proper footwear, while staff turned away to retrieve equipment. Additional observations showed staff improperly using mechanical lifts with the base in the closed position, causing instability and unsafe transfers for multiple residents. Staff interviews revealed a lack of understanding of safe transfer techniques and failure to follow both facility policy and manufacturer instructions.
A resident with a history of schizoaffective disorder and other chronic conditions did not receive prescribed antipsychotic medications for two weeks after admission due to staff entering orders for a different individual with the same name. The error, which was not identified during medication reconciliation, resulted in the resident experiencing psychosis, agitation, withdrawal symptoms, and hospitalization with a stage 3 sacral pressure ulcer.
Surveyors observed persistent unsanitary kitchen conditions, including standing water, a broken sink, damaged floors and ceilings, and excessive ice buildup in cold storage. Staff were seen handling food with bare hands and serving food with inadequate temperature control and improper covering, resulting in at least one resident refusing a meal. Staff interviews confirmed these issues were ongoing and contrary to facility policy.
Two residents with intact cognition reported that their food was often cold and bland, with one specifically noting issues with room tray service. Observation confirmed that hot foods were served below recommended temperatures and ice cream was not properly frozen, contrary to facility policy requiring food to be served at palatable temperatures.
Staff did not properly secure resident health information, including leaving a document with resident-specific details face-up on a medication cart and an unattended, open laptop displaying multiple residents' EHRs in areas accessible to mobile residents. Staff acknowledged these lapses, and facility policy requires such information to be protected at all times.
Staff failed to follow infection control protocols, including not wearing gloves or discarding contaminated medication, not using gowns or performing hand hygiene during wound and catheter care for residents on Enhanced Barrier Precautions, and not disinfecting mechanical lifts between resident uses, despite facility policy and expectations.
A resident with a history of incontinence and requiring assistance with toileting requested help from an LPN after wetting herself. The LPN did not provide immediate assistance or call for help, instead continuing medication administration and instructing the resident to wait in her room. The CNA was asked to assist but delayed care while attending to other residents, resulting in the resident waiting over 10 minutes for incontinence care and expressing feelings of being disregarded.
A resident with anxiety, depression, and osteoarthritis received psychotropic medications, but the care plan did not specify target behaviors for staff to monitor or include non-pharmacologic interventions. Documentation showed a range of behavioral issues, and staff confirmed that care plans were expected to include these elements, as required by facility policy.
A facility failed to maintain accurate and consistent counts of controlled medications, resulting in a card of Percocet prescribed to a resident becoming unaccounted for, along with missing count sheets. Staff interviews revealed confusion and inconsistencies in the medication counting process, including improper combining of count sheets, conflicting staff accounts, and a discontinued controlled medication remaining in the cart. These failures led to the inability to properly account for controlled substances as required.
A resident admitted with chronic pain, anxiety, and multiple diagnoses did not have a baseline care plan developed within 48 hours as required. The care plan was delayed, lacked documentation of chronic pain and psychotropic medication use, and was missing a date, time, and confirmation signature from the resident or family. Staff confirmed the process was not followed according to policy.
A resident with severe cognitive impairment and a right heel pressure ulcer was repeatedly observed without prescribed Prevalon boots, despite physician orders and care plan directives. Staff interviews confirmed the resident was non-weight bearing, had not refused care, and that the boots could not be located or were not applied as required. Nursing staff were unaware of the omission, and there was no documentation of refusal or notification to the nurse.
Two residents requiring oxygen therapy did not receive care in accordance with professional standards, including failure to change and label oxygen tubing as ordered and lack of access to a prescribed Bi-pap machine due to it being missing. Staff provided inconsistent and inaccurate documentation regarding respiratory care, and facility policy for equipment management was not followed.
The facility allowed non-pharmacist staff to draw up Morphine and Lorazepam in syringes, which were then placed unlabeled in medication carts for residents. Additionally, the facility failed to maintain accurate drug records and reconciliation for controlled substances, with several instances of missing counts for medications like Pregabalin and Morphine. These actions violated the facility's policies on medication storage and handling.
The facility failed to respect residents' dignity and self-determination, with incidents of a CNA forcing a resident to bed and handling her roughly, and another resident experiencing rudeness and disrespect. Staff were also observed entering rooms without waiting for an invitation, despite the facility's policy on treating residents with respect.
The facility failed to ensure call lights were within reach for four residents, as observed and confirmed through staff and resident interviews. Call lights were found on the floor or hanging down the side of the bed, making them inaccessible. Residents reported issues with call light accessibility, and staff acknowledged that call lights were often out of reach, contrary to facility policy.
The facility failed to provide a clean and homelike environment, with observations of dried food and stains in a resident's room, and persistent foul odors in hallways. Staff confirmed these conditions, and the facility's policy on cleaning lifts was not adhered to.
A facility failed to properly transfer a resident requiring an assistive device, neglected oral care for two residents, and did not groom a female resident's facial hair. A resident with dementia was transferred without the necessary lift device, causing distress. Oral hygiene was inadequate, with one resident's dentures uncleaned and another's toothbrush entangled with hair. A resident with MS was observed with unwanted facial hair. Facility policies on resident handling and ADLs were not followed.
Facility staff failed to properly assess and follow up on incidents involving residents, leading to deficiencies in care. A resident with severe cognitive impairments fell and sustained a hematoma, but staff did not conduct required follow-up assessments. Another resident had a skin tear with no documented treatment order or follow-up. Additionally, medications for two residents were administered outside prescribed time frames, violating facility policy.
The facility failed to maintain a pest-free environment, with staff and family members observing cockroaches throughout the facility, including in resident rooms and on medication carts. Despite pest control measures, the infestation persisted, and the exterminator company indicated that more aggressive treatment was needed, which required corporate approval.
A facility failed to implement a care plan for a resident with Multiple Sclerosis who required assistance with personal hygiene. Despite the care plan indicating the need for staff assistance with shaving, observations showed the resident had unshaved whiskers, which she expressed dissatisfaction with. The facility's policy required staff to provide necessary grooming services for residents unable to perform ADLs independently.
A deficiency was found in the treatment administration process when an LPN documented a treatment as completed for a resident with Xeroderma, despite it not being performed. The LPN relied on information from another LPN who claimed to have done the treatment. Facility policy requires accurate documentation in the EMAR system after administering medications.
The facility failed to secure medication carts and provide adequate supervision for a high-risk resident. Unlocked and unattended carts were observed in various locations, contrary to policy. A resident with severe cognitive impairments and a high fall risk was left unattended, resulting in a fall and injury. Staff confirmed the resident should not have been left alone.
The facility failed to properly label and store liquid Morphine and Lorazepam for three residents. Unlabeled syringes were found in medication carts, and staff admitted to pre-drawing these medications without proper labeling. The practice had been ongoing for months, contrary to facility policies requiring pharmacist involvement in pre-setting up such medications. Additionally, a bottle of Morphine was found without proper documentation, highlighting a lack of adherence to storage and labeling protocols.
Facility staff failed to don PPE while providing care to residents with catheters and PICC lines, despite signage indicating the need for enhanced barrier precautions. An RN and an LPN were observed not wearing gowns during procedures, and catheter tubing was found on the floor. Staff interviews confirmed inconsistent PPE usage, indicating lapses in infection control practices.
A resident with multiple diagnoses, including hemiplegia, experienced a fall during a transfer in an LTC facility. The facility failed to conduct and document necessary assessments and interventions following the fall and prior to transferring the resident to a hospital. Despite policies requiring documentation and follow-up assessments, these were not completed, leading to a deficiency in care.
A resident with a complex medical history, including end-stage renal disease and hemiplegia, was admitted with a left heel blister that was not addressed in the care plan until ten days later. The facility delayed initiating treatment for the blister and failed to complete required weekly skin assessments and Braden Scale evaluations. This led to the development of a necrotic area on the resident's heel, highlighting a deficiency in the facility's adherence to its pressure injury surveillance policy.
A resident with multiple medical conditions and non-weight bearing status required two staff for transfers using a sliding board. However, during a transfer, only one CNA was present, leading to the resident losing balance and falling. Despite being aware of the two-person requirement, the CNA proceeded alone after the resident indicated they could manage it together. No injuries were reported, but the incident highlights a failure to follow established care plans and protocols.
The facility failed to follow physician orders for catheter care for two residents, resulting in discrepancies in catheter size and lack of proper documentation. Both residents required maximum assistance and had indwelling catheters, but the care plans were not adhered to, and the interim DON was unaware of the reasons for these deficiencies.
A resident with moderate cognitive impairment reported being handled roughly by a male CNA during a transfer, leading to anxiety and bruising on her ankles. Despite family concerns, the facility did not thoroughly investigate or report the incident, and the staff member continued to provide care. The facility's limited response and lack of disciplinary action highlight a deficiency in ensuring resident dignity and respect.
A facility failed to ensure consistency between a resident's IPOST and Care Plan regarding code status. The resident had a DNR order in the physician's orders and IPOST, but the Care Plan indicated a request for CPR/full code status. The facility's policy required updates to the care plan for any changes in directives, but this was not done, as acknowledged by the Administrator. Staff usually referred to the IPOST for code status, resulting in the inconsistency.
A resident with moderate cognitive impairment reported being handled roughly by a male staff member, resulting in bruising on her ankles. Despite the family's report, the facility did not report the incident to the State agency, failed to conduct a thorough investigation, and allowed the staff member to continue working with residents. The facility's actions were inconsistent with their policy on abuse prevention and investigation.
A resident with moderate cognitive impairment and multiple medical conditions reported being handled roughly by a male staff member during a transfer, resulting in bruising. The facility failed to conduct a thorough investigation, did not interview the staff member involved, and did not report the incident to the Department of Inspections and Appeals and Licensing (DIAL). The staff member continued to work at the facility and provide care to the resident.
A facility failed to notify the LTC Ombudsman of a resident's discharge to the hospital, as required by federal regulation. The resident was discharged and later reentered the facility, but the clinical record lacked documentation of the required notification. The Administrator confirmed the omission, which was contrary to the facility's policy on Transfer and Discharge.
A facility failed to refer a resident with PTSD for a Level II PASARR evaluation despite the diagnosis being known at admission. The resident's MDS indicated severe cognitive impairment and diagnoses of major depressive disorder and PTSD, yet the facility did not complete a Level II PASARR. The administrator noted the absence of a specific PASARR policy, with responsibility assigned to a part-time social worker.
A facility failed to implement a comprehensive care plan for a resident with a urostomy, leading to inadequate care and documentation. The resident, who is cognitively intact and has a neurogenic bladder, reported infrequent emptying of the urostomy bag. The care plan lacked instructions for bag care and monitoring, and documentation was inconsistent. The DON acknowledged these deficiencies, noting the expectation for regular emptying and documentation.
Failure to Assist With Eating and Implement Nutritional Interventions for Residents With Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with eating and to implement ordered nutritional interventions for two residents with significant weight loss and high ADL dependence. One resident with non‑Alzheimer’s dementia, anxiety, abnormal weight loss, and mechanically altered diet required substantial staff assistance for all ADLs, including eating, and was unable to stand or ambulate. Her weights showed a 5.75% loss in one month and 11.5% in six months, both significant. The RD/LD notes documented ongoing weight loss, fair intake of a mechanical soft diet, variable supplement intake, and recommendations to continue house supplements and shakes; however, the April MAR/TAR did not show documentation that shakes were ordered or provided, and there were no additional physician orders addressing the significant weight loss identified on 3/19/26. Her care plan directed one‑person assistance with eating, monitoring for aspiration and dysphagia signs, serving supplements per orders, and providing chocolate shakes (called “B‑Bop shakes”) with lunch and supper. Despite these care plan directions and staffing levels that included 11 CNAs on the day shift, observations in the dining room showed prolonged periods where this resident sat with untouched food and no feeding assistance. On one observed lunch, she was seated near an open window in cool outdoor temperatures, initially with her arms under a blanket and a glass of juice out of reach. After her grilled cheese sandwich and dessert were served, staff removed crusts but did not cut the sandwich into bite‑sized pieces or assist with feeding. For more than 20 minutes, she remained at the table with food untouched while CNAs assisted other residents or sat unoccupied at the nurses’ station. Feeding assistance did not begin until approximately 25 minutes after food service, at which point she consumed only a small amount of dessert and juice, and no other food was offered. On another day, she was observed seated waiting for breakfast and then removed from the dining room without eating after a CNA reported she did not want to eat. Family reported finding her repeatedly with cold food and no staff assistance, stated she was unable to feed herself, and said they had reported these concerns to management multiple times without change. The second resident had anemia, thyroid disorder, non‑Alzheimer’s dementia with severe cognitive impairment, and significant weight loss documented on the MDS. She required substantial/maximal assistance for most ADLs and supervision or touch assistance for eating. Her weights showed a 13.9% loss over six months. Physician orders included a house supplement 60 ml three times daily, and RD/LD notes described variable supplement intake, a puree diet with about 50% intake, a stage III pressure sore, and recommendations for additional protein supplementation and weekly weights. Her care plan identified risk for impaired nutrition related to malnutrition, dementia, failure to thrive, altered diet, and significant weight loss, with goals for three meals daily and a target weight range, and directed staff to provide set‑up/assist as needed, serve diet and supplements as ordered, and obtain weights with MD notification of significant changes. Dining room observations for this resident showed that, like the first resident, she did not receive timely feeding assistance despite her cognitive impairment and care plan directions. On one lunch, she was brought to the table and left without assistance while her tablemate’s food remained untouched; later, she received a plate of pureed food that sat uncovered for about nine minutes before any staff began feeding her, even though multiple CNAs were present in the dining room and at least one CNA sat idle at the nurses’ station. On another day, she had pureed food in front of her with no feeding assistance until a CNA sat down and began to help, and she had not attempted to feed herself. Staff interviews, including the DON and CNAs, confirmed expectations that staff should be present in the dining room to assist residents who require feeding help, that three CNAs were assigned to dining room feeding, and that staff were expected to serve and assist with ordered supplements. Nonetheless, the observed lack of timely feeding assistance and the absence of documented implementation of ordered nutritional interventions for both residents occurred in the context of significant, documented weight loss.
Failure to Provide and Document Ordered Wound Care and Maintain Infection Control During Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide and document ordered pressure ulcer and wound treatments and to use proper infection control techniques during wound care for two residents with significant skin breakdown. For one resident with severe cognitive impairment, coronary artery disease, heart failure, and Alzheimer’s disease, the MDS identified total dependence for most ADLs and the presence of multiple pressure ulcers, including two unstageable ulcers. Physician orders directed daily and PRN treatments to the left heel, right coccyx, left buttock, and right buttock, as well as weekly skin assessments. Review of the March and April Treatment Administration Records (TARs) showed numerous instances where these ordered treatments were not signed out as completed on multiple dates for each wound site, including missed documentation for the left heel, right coccyx, sacrum, and bilateral buttocks. For this same resident, the care plan identified a pressure ulcer and risk for pressure ulcer development and directed staff to administer treatments as ordered and observe for effectiveness. Despite this, the TARs reflected repeated omissions in documenting completion of ordered wound care across several days and shifts. Although an observation of wound care in early April showed appropriate use of isolation gown, gloves, and hand hygiene with wounds appearing without signs of infection, the record review still demonstrated that multiple scheduled treatments were not recorded as completed. The DON stated that after a nurse completes a treatment, the nurse is expected to initial the TAR immediately, but could not provide specific reasons for the missing treatment documentation. The second resident was cognitively intact with renal insufficiency, diabetes mellitus, spina bifida, an indwelling urinary catheter, and at least one Stage IV pressure ulcer, and was totally dependent for most ADLs. This resident had multiple wounds, including an unstageable left heel ulcer, a right foot wound, and wounds to the right medial lower leg and left posterior thigh, with physician orders specifying cleansing solutions, dressings, and scheduled frequencies. During observed wound care, two LPNs donned gowns and gloves, but one LPN failed to disinfect scissors between cutting off old dressings and cutting new dressings, and did not change gloves between cleansing a wound and handling new dressings. The same LPN also did not cleanse or redress an open necrotic wound on the bottom of the right foot during the observation after removing the dressing, based on another staff member’s statement that the area had been healed and the dressing discontinued. Review of the physician orders and April TARs for this resident showed additional instances where ordered treatments to the left heel, right foot, and other wound sites were not signed out as completed on multiple dates. Facility policies required medications and topical treatments to be administered and documented per orders and required appropriate wound interventions and documentation, but the observed practices and missing TAR entries did not conform to these requirements.
Failure to Obtain Catheter Orders and Maintain Catheter Infection-Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper physician orders and infection-control practices for indwelling urinary catheters. One resident with obstructive uropathy, hydronephrosis, renal and ureteral calculous obstruction, hemiplegia, sepsis, gross hematuria, and bacteremia had a urinary catheter in place and was care planned for catheter management, including enhanced barrier precautions and proper positioning of tubing and drainage bag. A urinalysis and culture showed more than 100,000 CFU/mL of Proteus Mirabilis/Penneri, and the resident was treated with intramuscular Ceftriaxone. A CT scan performed during a hospitalization for heart arrhythmia, gross hematuria, UTI with sepsis, and renal calculi showed multiple coarse calcifications surrounding the urinary catheter, indicating the catheter could not have been changed on the date documented in the record. Another resident, cognitively impaired and totally dependent for all ADLs, with hemiplegia after stroke, gastrostomy, and slow transit constipation, was incontinent of bowel and bladder and returned from the hospital with an indwelling urinary catheter. The hospital discharge instructions did not include orders for the catheter, the facility’s order summary lacked any catheter order, and the resident’s care plan did not document the presence of the indwelling catheter. Nursing staff reported that when a resident returns from the hospital with a catheter and no order, the nurse should call the physician within 24–48 hours, and the DON stated she expected a call for orders within 24 hours, but this was not done for this resident. Surveyor observations showed repeated failures to maintain catheter tubing and drainage bags off the floor and properly positioned. For the first resident, after a CNA transferred the resident from wheelchair to bed, the urinary catheter bag was observed lying directly on the floor near the bed. For the second resident, the Foley bag was hanging below bladder level on the side of the bed facing the open doorway, visible from the hall, and the Foley tubing lay on the floor for an extended period. Multiple staff members, including CNAs, an RN/ADON, and an LPN, walked past or entered the room numerous times without picking the tubing up from the floor. Only after a CNA entered the room wearing isolation gown and gloves to empty the Foley bag was the tubing finally picked up. The facility’s catheter care policy required that catheter tubing and drainage bags be kept off the floor, which was not followed in these instances.
Failure to Prevent Significant Medication Errors and Unauthorized Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors by allowing unassessed residents to self-administer medications and by preparing and issuing medications to multiple residents simultaneously. Resident #1 had a BIMS score of 15, indicating intact cognition, but there was no physician order for self-administration of medications in his clinical record. During an observation in his room, a medication cup with two small white pills was found on his bedside table. Resident #1 stated the pills were Tylenol and reported that staff routinely left his medications on the table for him to take on his own, usually without observing him ingest them. Resident #16 also had a BIMS score of 15 and diagnoses including anemia, hypertension, heart failure, renal insufficiency, and seizure disorder or epilepsy. Her clinical record likewise did not contain an order for self-administration of medications. Nursing progress notes documented that during a night shift, a staff member prepared medications for Resident #16 and her roommate at the same time, entered the room, and gave both residents their medications without observing them take the doses, leaving the medications with the residents instead. When the staff member returned, the roommate reported that the name on the medication cup she had been handed was not hers, and the staff member realized the residents had been given the wrong medications. The notes further documented that Resident #16 had already consumed her roommate’s medications, which included Simvastatin 40 mg, Gabapentin 600 mg, and oxybutynin chloride 5 mg, and that she subsequently experienced a change in mental status, increased thirst, and increased desire to sleep. Multiple staff interviews, including with the LPN who made the error, CMAs, the ADON, and the DON, confirmed that facility expectations and written policy required staff to administer medications to one resident at a time, verify resident identity, observe medication ingestion unless there was an order for self-administration, and prohibit leaving medications at the bedside without such an order. Despite these policies and prior education, staff acknowledged that medications had been left in resident rooms and that multiple residents’ medications had been prepared and passed at the same time, leading to the documented medication errors involving Residents #1 and #16.
Failure to Follow Enhanced Barrier and Transmission-Based Precautions for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP) and transmission-based precautions, for multiple residents. For one resident with obstructive uropathy, UTI, hemiplegia, sepsis, gross hematuria, and bacteremia who had an indwelling urinary catheter and an order for EBP with gown and gloves for high-contact care including transfers, a CNA transferred the resident from wheelchair to bed without any PPE, despite an EBP sign and PPE supplies on the door. The CNA stated it was only his second or third day working there, that he had seen other staff enter without PPE, and did not think PPE was required. During this same observation, the resident’s urinary catheter drainage bag was noted lying directly on the floor near the bed. The Administrator later stated the facility did not use skills competency checklists and that new staff were oriented by working with another employee until they felt they no longer needed guidance. Another deficiency occurred when a CNA encountered two rooms with doors open that were marked for Transmission Based Precautions and Droplet Precautions. The room on droplet precautions housed a resident recently returned from the hospital with Parainfluenza Virus, and the other room housed a resident on isolation precautions for Clostridium difficile. The CNA stated he did not know whether the doors should be open or whether the residents were on droplet or transmission-based precautions. When asked to close the doors, he entered both rooms without donning any PPE to inform the residents he was closing the doors. The DON later confirmed that one resident was on droplet precautions and the other on isolation, and that the doors should not have been left open to the hallway. A further deficiency was identified in the care of a resident with cancer, neurogenic bladder, coronary artery disease, MS, and a suprapubic catheter, who was totally dependent on staff for toileting, showers, dressing, footwear, and repositioning, and had an indwelling urinary catheter and bowel incontinence. The care plan and physician orders directed staff to follow EBP and to use gown and gloves for high-contact care, including peri care, assisted toileting, and catheter/device care every shift. During observed incontinence care after a bowel movement and subsequent emptying of the catheter bag, a CMA/CNA wore gloves but did not don an isolation gown for either task. Multiple staff (CNAs, an LPN, and the DON) later described that appropriate catheter care should include donning a gown and gloves, consistent with the facility’s Infection Control Precautions Summary, which specified gown and gloves for EBP during dressing, bathing/showering, transferring, hygiene, changing linens, changing briefs/toileting, and device care such as catheter care.
Failure to Provide Ordered Catheter Care, Monitor Urine Output, and Complete Antibiotic Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered catheter care, monitor urinary output as directed, and ensure complete administration of prescribed antibiotics for residents with indwelling urinary catheters. For one resident with multiple sclerosis and neurogenic bladder who used an indwelling catheter, the care plan directed staff to empty the catheter bag every shift and as needed, and a physician’s order required staff to record catheter output every shift. However, review of the Treatment Administration Records (TARs) over several months showed numerous missing entries for catheter output, with output not recorded for a significant number of shifts in December, January, and February despite the standing order to monitor output each shift. Another resident with obstructive uropathy and an indwelling catheter had multiple hospitalizations related to urinary issues, including sepsis secondary to UTI, enterococcal bacteremia, and complicated UTI. The care plan for this resident identified the presence of an indwelling catheter and directed staff to encourage fluids and check catheter tubing for kinks each shift, but it lacked specific directives for the provision and frequency of catheter care despite an existing physician order for catheter care every shift and as needed. TAR review showed multiple dates over several months where catheter care was not documented as provided, and there was also an order to record urine output that was not consistently followed, with numerous days lacking recorded output. Additionally, although there was an order to change the catheter as needed for leakage, dislodgement, or occlusion, there was no documentation of any catheter change over a several‑month period. The same resident had an order for Amoxicillin 500 mg PO BID for a total 9‑day course to treat a UTI following hospitalization. The MAR showed missing doses on multiple days, and there was no documentation that the antibiotic was administered for one dose on one day and for all doses on two subsequent days. Pharmacy records from the prior vendor confirmed that only 10 tablets (a 5‑day supply) of Amoxicillin were dispensed, even though the order was for a 9‑day course, and the new pharmacy vendor had no record of dispensing Amoxicillin for this resident. Staff interviews revealed inconsistent practices and instructions regarding reordering medications, use of the E‑kit, and documentation when medications were unavailable, including a CMA’s report that she was told by nursing leadership not to document that a medication was not available or awaiting delivery. The resident ultimately required hospitalization for sepsis secondary to UTI and urinary retention, and later for a complicated UTI, after not receiving the full ordered course of antibiotics and with gaps in ordered catheter care and urine output monitoring. Staff interviews further showed confusion and inconsistency in following and documenting physician orders, including lab orders for urinalysis and culture, and in using the electronic health record to track orders and results. The NP reported that orders were written with the expectation that facility management would enter and ensure they were carried out, but that there were frequent instances where orders, including antibiotics, were not followed. The DON and nursing staff described differing understandings of when to change catheters and how to document unavailable medications, with some staff stating they were told not to document unavailability. Collectively, these actions and inactions led to missed catheter care, incomplete monitoring of urinary output, and failure to administer a complete antibiotic course as ordered for residents with indwelling catheters and UTIs. Resident #1 did not receive a full nine-day course of antibiotics to treat a UTI which resulted in a hospitalization.
Persistent Pungent Odors Compromise Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment due to persistent pungent odors on two of three nursing units (Station 1 and Station 2). Surveyors repeatedly detected strong, unpleasant odors in specific areas, including near the shower room and environmental services door on Station 2, and down the East hallway on Station 1. These odors were present at multiple times over several days, sometimes lingering for hours and recurring after temporary reduction. On one occasion, an uncovered trash and linen cart containing trash, soiled briefs, and soiled linens was observed in the Station 2 hallway, contributing to unpleasant odors. Staff interviews confirmed awareness of the ongoing odor problem. The Housekeeping Director reported using a deodorizing machine about twice weekly and as needed, without a set schedule for specific units, and acknowledged that the odor is present daily, suspecting it may be related to personal habits of several residents. The Housekeeping Director stated staff were instructed to change bedding daily and empty trash in a timely manner. The Maintenance Assistant also acknowledged the odors, particularly on Station 1 East hallway, and suspected the carpets as a source, noting they are shampooed once per month. The Administrator acknowledged the pungent odors throughout the building. Facility policy on Quality of Life–Homelike Environment requires staff and management to maximize a personalized, home-like setting with pleasant, neutral scents and to minimize institutional odors, which was not achieved based on these observations.
Failure to Follow Infection Control Practices for Insulin Administration, Catheter Care, and Hand Hygiene
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices, including improper use of multi-dose insulin pens, inadequate hand hygiene, and incorrect use of personal protective equipment (PPE) and supplies during resident care. For one resident with diabetes mellitus, anxiety disorder, and heart failure, who was cognitively intact and received insulin, the clinical record showed that an LPN administered various types of insulin on multiple dates. Facility policy stated that multi-dose insulin pens were for single-resident use only and that changing the needle did not make it safe to use insulin pens for more than one resident. Despite this, the LPN later reported that she borrowed insulin pens from other residents who used the same type of insulin and did not know which residents the pens originally belonged to. Another cognitively intact resident with diabetes mellitus, muscle weakness, and a cognitive communication deficit also received insulin injections. The resident’s care plan did not address insulin use. The medication administration record documented that the same LPN administered long-acting and fast-acting insulin to this resident on several dates. A corrective action form and staff interviews described that this LPN did not dispose of insulin pens from discharged residents and reused those pens, as well as other current residents’ pens, for multiple residents using the same type of insulin. One LPN reported finding a bag of insulin pens with multiple resident names and a pen with a used, blood-contaminated needle attached, and stated she was instructed by the LPN to use these pens until they were gone. The deficiency also includes failures in basic infection control practices during catheter care and personal care for residents on Enhanced Barrier Precautions (EBP). One resident with benign prostatic hyperplasia, diabetes, a history of stroke, and an indwelling urinary catheter required catheter care every shift and was on EBP. During observed care, a CNA donned a gown and gloves without performing hand hygiene, placed a urine graduate directly on the bathroom floor without a barrier, drained the catheter bag into the graduate, and then used the same contaminated gloves to handle her gown, reach into her uniform pocket for an alcohol swab, cleanse the catheter port, open the bathroom door, and empty the graduate into the toilet. The CNA then placed the graduate on a paper towel by the toilet, removed PPE, and proceeded to other resident care tasks without documented hand hygiene between activities. Facility policies required hand hygiene before, during, and after care, glove changes between dirty and clean tasks, single-use gloves, and proper handling and placement of the graduate, but these steps were not followed. Additional observations of personal care for another resident showed staff not performing hand hygiene or changing gloves between dirty and clean tasks. During incontinence care and dressing, staff used gloved hands to remove a soiled brief, clean the genital area after a bowel movement, reposition the resident, adjust bedding, and then change the resident’s clothing and handle the resident’s head/face area, all without changing gloves or performing hand hygiene until after the care was completed. Facility policies on hand hygiene and glove use required hand hygiene at the start and end of care, and whenever moving from a contaminated task to a clean task, as well as single-use gloves to be discarded after each use. These observed practices did not comply with the facility’s infection prevention and control program, catheter care policy, PPE policy, or hand hygiene policy.
Failure to Supervise Medication Administration and Unauthorized Self-Administration
Penalty
Summary
Surveyors identified a deficiency in medication administration supervision for Resident #4, who had intact cognition with a Brief Interview for Mental Status score of 15 and diagnoses including atrial fibrillation, anxiety, arthritis, depression, diabetes, edema, and hypertension. The resident’s care plan, last revised on 10/20/25, documented that the resident was resistive to cares and had a history of refusing medications if they did not feel the medications were necessary, with interventions directing staff to educate the resident on possible outcomes of noncompliance. The care plan did not document that the resident could self-administer medications. The MAR and current physician orders directed staff to offer two different medications mid-morning for a total of three pills and did not indicate that the resident was allowed to self-administer medications. During an observation, a CMA entered the resident’s room with a small cup containing three pills, placed it on the bedside table in front of the resident, visited briefly, and then left the room without acknowledging or administering the medications, which remained on the bedside table. The DON stated that staff are required to stay with residents when administering medications and should not leave residents alone with medications. CMAs interviewed reported that no residents were independent to keep medications in their rooms and that they would not leave medications with a resident in their room. The resident confirmed that medications were left in their room by staff and reported that this occurred periodically. Facility policy on administering medications stated that medications shall be administered in a safe and timely manner as prescribed, and that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined the resident has the decision-making capacity to do so safely.
Failure to Follow Physician Orders and Track Return of Cardiac Event Monitor
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards related to the use, monitoring, and return of a prescribed cardiac event monitor for one resident. The resident was admitted from an inpatient psychiatric facility with diagnoses including atrial fibrillation, hypertension, catatonic disorder, and major depressive disorder, and had intact cognition. The hospital discharge summary documented that cardiology recommended a 2‑week heart monitor at discharge with electrophysiology follow‑up. Despite this, the resident’s care plan revised on 12/29/25 contained no information about the heart monitor, and the facility lacked documentation that the monitor was applied on admission as expected by the clinic. An order was entered on 1/3/26 by an LPN to monitor the heart monitor for placement every shift and to mail the monitor back on Friday and discontinue the order when done, with an order end date of 1/6/26. However, the Medication Administration Record and Treatment Administration Record for that month contained no documentation that staff monitored the placement of the heart monitor. Progress notes showed the resident arrived on 12/17/25 and that on 12/24/25 a family member requested staff place the monitor, but there were no further notes describing when the monitor was applied, how long it was worn, when it was removed, or who removed it. Multiple CMAs and CNAs interviewed either were unaware of the monitor or could not recall the resident wearing it, while one LPN recalled reapplying the monitor after it came off, and another CNA recalled giving the removed monitor to an LPN who no longer worked at the facility. The facility also failed to have or follow a process for tracking and returning the monitor to the vendor. Staff interviews revealed confusion about who was responsible for entering and managing the monitor orders, handling the device, and arranging its return. One LPN reported removing the monitor, packing it, and taking the box to the DON’s office 3–4 weeks prior to the survey, after calling the vendor’s 800 number and involving an ADON who later left employment. The DON initially stated she did not believe the resident had a monitor and did not know if one was received, later reporting that she mailed a labeled box by dropping it in a downtown post office mailbox without knowing its contents or required shipping method, and acknowledging there was no specific person or department responsible for outgoing mail or package tracking. The University Hospital Clinic confirmed they had not received the monitor or data, that their system still showed they were waiting for data, and that the monitor should have been applied on the admission date and returned via UPS after the 15‑day recording period. The administrator confirmed there was no mail policy, and the facility could only produce a medication order policy rather than a broader physician’s orders policy, while the resident assessment policy required that assessment information be consistent with progress notes and care plans, which did not occur in this case. The deficiency is further supported by the family’s report that the monitor was not placed until about a week after admission, that it had been left on the floor before being reapplied, and that the hospital called about the monitor being three weeks overdue. Facility records lacked any process for tracking the disposition of the monitor or ensuring it was returned to the appropriate vendor or provider facility. The clinic nurse confirmed that, because the monitor had not been received, they were unable to download the information to determine if there was any arrhythmia, and that the computer system still showed they were waiting for data. The NP stated she wrote orders and expected them to be processed and followed, and that she informed facility management when orders were not carried out, noting that this happened frequently. Overall, the documented lack of care plan integration, missing monitoring documentation, unclear responsibility for the device, and absence of a mail/return process led to the monitor not being timely returned, delaying data analysis and physician follow‑up for this resident. The facility’s own documentation and staff statements show that the resident should have had the monitor applied on admission and worn it for the prescribed period, with staff monitoring its placement each shift and returning it promptly per the order. Instead, there were gaps in documentation, inconsistent staff awareness of the monitor, and no clear chain of custody or tracking once the device was removed. The DON and regional leadership acknowledged the absence of a mail policy and the lack of a defined process or tracking system for outgoing packages, including medical devices such as the heart monitor. The University Hospital Clinic’s confirmation that no monitor or data had been received, combined with the facility’s inability to verify when or how the monitor was shipped, demonstrates that the facility did not ensure services were provided in accordance with professional standards and physician orders for this resident.
Failure to Consistently Provide and Document Scheduled Resident Bathing
Penalty
Summary
The deficiency involves the facility’s failure to consistently offer and provide scheduled bathing assistance to dependent residents, despite care plans and schedules indicating the need for regular showers or baths. Resident #5, who had intact cognition with a BIMS score of 15 and diagnoses including arthritis, chronic pain syndrome, and heart failure, required staff assistance with bathing and showers per the care plan. Documentation for December and January showed that bathing was scheduled twice weekly on Tuesdays and Fridays, but in December baths were documented as completed only four out of nine scheduled days, and in January only two out of nine scheduled days. There was no documentation for the remaining scheduled bath days to indicate whether bathing was completed, not offered, or refused. Resident #5 reported going over two weeks between showers, stated that baths or showers were often not offered, and noted having to ask for a shower, particularly during January. Resident #3, admitted with osteoporosis and major depressive disorder and dependent on staff for bathing, also had a BIMS score of 15 indicating no cognitive impairment. According to a family member interview, the resident did not receive a first shower until 19 days after admission, and after that first shower, the family was told the resident would receive showers twice weekly. However, the family member reported the resident went eight days before the next shower and received only two showers in a 30‑day period. Documentation Survey Reports for showers covering December and January confirmed that from 12/17/25 to 1/17/25, the resident received showers only on 12/31/25 and 1/8/26. Resident #1, who had intact cognition with a BIMS score of 15 and was dependent on staff for transfers and bathing, had a care plan identifying an ADL self‑care performance deficit related to pain and impaired balance and mobility, with staff directed to provide assistance of one for bathing. The bath schedule showed this resident’s room was assigned baths on Tuesday and Friday mornings. Review of paper bath sheets and Documentation Survey Reports from November through January revealed that baths were documented as completed on only a small fraction of the scheduled bath days: two of nine in November, one of nine in December, and two of nine in January, with one documented refusal and one missed bath due to hospitalization. Multiple staff interviews confirmed that CNAs were responsible for baths, used room‑based bath schedules, and were expected to document in both paper bath sheets and the computer, but staff acknowledged that paper bath sheets frequently were not completed. The DON and other staff described prior lack of a clear process and issues with scheduling and documentation of baths, while the facility’s ADL policy required that residents unable to carry out ADLs independently receive services necessary to maintain good grooming and personal hygiene, including bathing.
Failure to Complete and Document Neuro-Checks and Full-Body Skin Assessments After Multiple Unwitnessed Falls
Penalty
Summary
The deficiency involves the facility’s failure to complete and document neurological assessments and full-body skin assessments as ordered and care planned for a resident with multiple risk factors. The resident had intact cognition but significant medical conditions including anxiety, aphasia, diabetes, heart failure, hemiplegia, and a history of stroke, and was dependent on staff for all care and transfers. The resident had two or more falls since the prior MDS assessment, was at risk for pressure injuries, and had a diabetic foot wound and an open foot lesion. The care plan included neuro-checks per facility policy for falls and skin inspections due to self-care deficits. Facility incident reports showed 21 unwitnessed falls over several months, but neuro-checks were initiated and documented for only 13 of these falls, and 8 of those 13 neuro-check forms were incomplete, missing one or more of the scheduled assessments required by the facility’s Falls Management System policy and Neurological Assessment form. The facility also failed to consistently complete and document full-body skin assessments for this resident. Weekly full-body skin reviews were documented from late July through early November, but no full-body skin assessments, either electronic or paper, were identified from mid-November through the end of December. During this period, only focused diabetic/neuropathic foot evaluations were documented, which did not address the rest of the body. Progress notes identified a bruise near the left upper eye area and, later, a bruise and skin tear to the right elbow following a fall, as well as cuts on the resident’s hand from fingernails, with treatment orders initiated. However, there was no further documentation in progress notes or skin assessments tracking these injuries. Staff interviews confirmed that neuro-checks for unwitnessed falls were expected to be completed and documented, and that full-body skin assessments were expected on bath days and during weekly skin assessments, but acknowledged that full-body checks were not consistently performed and documented for this resident.
Failure to Provide Nursing Coverage Results in Missed Medications and Resident Distress
Penalty
Summary
The facility failed to provide adequate nursing coverage for approximately four hours on two nursing units, affecting 53 residents, after one of two on-duty nurses left the facility unexpectedly during the night shift. This left only one nurse in the building, who did not assume responsibility for the other units, did not access the medication cart, and did not call for additional help. As a result, residents did not receive their scheduled or as-needed medications, and there was no licensed nurse in charge on each shift as required. One resident with chronic pain and a history of incomplete paraplegia, renal insufficiency, and chronic pain did not receive her scheduled pain medications, resulting in severe pain. She repeatedly requested her medications, but staff informed her that the nurse had left and no one could access the medication cart. The resident's pain became so severe that she called 911 for assistance. Emergency responders found her in visible distress, crying and screaming in pain, and confirmed that her medications had not been administered for several hours past the scheduled time. Another resident with a documented history of multiple anaphylactic reactions and systemic mastocytosis reported symptoms of an allergic reaction, including itching and facial swelling. She initially received Benadryl from the nurse before the nurse left, but when her symptoms worsened, she was unable to get further assessment or intervention from nursing staff. The resident ultimately self-administered her own epi pen, which she kept in her room, as no nurse responded to her call for help. A third resident also did not receive scheduled pain medication during this period. Staff interviews confirmed that there was confusion among staff regarding who was in charge, and no one took responsibility for the residents' care or medication administration after the nurse left.
Failure to Complete Post-Fall Follow-Up Assessments and Documentation
Penalty
Summary
The facility failed to complete required follow-up assessments after a resident experienced a fall. Clinical record review and staff interviews revealed that, although the interdisciplinary team met to discuss the fall and performed a root cause analysis, there was no documentation of follow-up actions such as pain assessments, vital signs, or neurological checks in the resident's record. Additionally, no incident report was found for the fall, and staff confirmed that the nurse on duty at the time did not initiate the required documentation. The absence of follow-up assessments and documentation occurred despite facility protocol requiring these actions after a fall.
Failure to Maintain Complete Medical Records for Resident Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards for three of four residents reviewed. For one resident, a progress note documented a witnessed fall and initiation of neurological checks, with subsequent notes referencing continued monitoring. However, the facility was unable to produce the neurological check sheets, as they were completed on paper and subsequently lost. Similarly, another resident experienced a fall, with a nursing note indicating neurological checks were started, but the corresponding documentation could not be located. In a separate incident, a progress note indicated that the interdisciplinary team met to discuss a resident's fall and implemented an intervention, but no incident report for the fall could be found. Staff interviews revealed that the nurse on duty at the time of the fall left her position abruptly after the incident, and although she assessed the resident and relayed information to another nurse, the required incident report was never completed. The facility's policy requires that medical records be organized and easily retrievable, but in these cases, essential documentation related to falls and follow-up care was missing.
Failure to Ensure Safe Transfers and Proper Use of Mechanical Lifts
Penalty
Summary
The facility failed to ensure resident safety during transfers, resulting in harm to a resident who was improperly transferred in the shower room. The resident, who had a history of seizure disorder, prior laminectomy, and was assessed as requiring partial/moderate assistance for transfers, was left standing at the grab bars without a gait belt and without proper footwear. The staff member assisting her turned away to retrieve a shower chair, leaving the resident unsupported, which led to the resident losing her grip and falling. The fall resulted in two fractures, increased pain, and a decline in the resident's ability to transfer. Observations of other residents revealed additional failures in the use of full body mechanical lifts. Staff were observed transferring residents with the adjustable base of the mechanical lift in the closed position, contrary to both manufacturer instructions and facility policy, which require the base to be in the open position for stability during transfers. This improper use caused residents to tilt and the lift to wobble during transfers, creating unsafe conditions. Staff interviews confirmed a lack of understanding regarding the correct positioning of the lift base, and some staff believed the lifts could only be moved with the base closed due to the age of the equipment. Facility documentation and staff interviews indicated that the use of gait belts and proper footwear were required for transfers, but these protocols were not followed during the incidents. The facility's own policies and the manufacturer's manual for the mechanical lift both emphasized the importance of these safety measures. Despite these clear guidelines, staff failed to implement them, resulting in unsafe transfers and resident harm.
Failure to Verify Resident Identity Leads to Significant Medication Error
Penalty
Summary
The facility failed to verify the correct identity of a newly admitted resident, resulting in the entry of incorrect medication orders into the Electronic Health Record (EHR). Admission paperwork received by the Director of Admissions and Marketing contained information for a different resident with the same name but a different date of birth. This error was not identified during the medication reconciliation process, and the orders were entered into the EHR without confirming the six rights of medication administration. As a result, the resident did not receive her prescribed antipsychotic medications for approximately two weeks following admission. During this period, the resident, who had a history of schizoaffective disorder, hypothyroidism, and other chronic conditions, exhibited significant changes in behavior and mental status. Progress notes documented medication refusals, emotional distress, agitation, and statements indicating psychosis and withdrawal symptoms. The resident's family noticed a decline and questioned whether the correct medications were being administered. It was later confirmed by the DON that the orders entered were not for the correct resident, and the error was only identified after the family raised concerns. The lack of proper verification and reconciliation led to the resident experiencing exacerbation of psychosis, agitation, and withdrawal symptoms, ultimately resulting in hospitalization. Upon return from the hospital, the resident had developed a stage 3 sacral pressure ulcer. Interviews with staff revealed that the process for verifying resident identity and medication orders was not consistently followed, and the policy for medication reconciliation was not adequately implemented, contributing to the significant medication error and subsequent harm to the resident.
Deficient Food Storage, Preparation, and Service Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple observations of unsanitary and unsafe kitchen conditions. Surveyors observed significant standing water covering half of the kitchen floor, a broken and leaking sink, uneven and missing floor tiles, and a collapsing ceiling with black spots above food preparation areas. The walk-in freezer had excessive ice buildup on the floor, walls, and food items, while the walk-in cooler contributed to the flooding issue. Staff interviews confirmed these issues were ongoing, had been repeatedly reported to management, and had persisted for months to years without resolution. No maintenance or service logs were available for the walk-in cooler or freezer. During meal service observations, staff were seen directly touching residents' food with ungloved hands on multiple occasions. One resident refused to eat a dessert after reporting that a staff member's finger had been in the food. Staff interviews confirmed that direct hand contact with food was against facility policy and that food should be replaced if touched. Additionally, room trays were observed with ill-fitting covers that did not properly protect the food during transport, and several trays sat uncovered and unserved in the hallway for extended periods, resulting in food being served at unsafe temperatures and melted ice cream. Facility policy documents reviewed by surveyors stated that food must be served at safe and appetizing temperatures, staff must never touch residents' food with bare hands, and food must be covered during transportation. The policies also required timely equipment repairs and regular defrosting of freezers. Despite these policies, the facility failed to maintain a safe and hygienic kitchen environment and did not ensure proper food handling and service practices, as evidenced by the direct observations and staff interviews.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to two residents with intact cognition, as identified through clinical record review, observation, and resident and staff interviews. One resident reported that the food was constantly cold and bland, while another stated that food served on room trays was often cold and bland. Direct observation of a sample tray revealed that the ham and green beans were served at 120.3°F and 119°F, respectively, and the ice cream was soft and not frozen. The facility's policy requires all food items to be served at a palatable temperature, but this standard was not met for the residents reviewed.
Failure to Secure Resident Health Information
Penalty
Summary
Staff failed to properly safeguard resident-identifiable information, resulting in unauthorized access to protected health information. On one occasion, an unsecured document containing resident-specific health information was observed face-up on a medication cart, accessible in a hallway where several residents were independently mobile. A staff LPN acknowledged that the document should have been placed face down but was left exposed when she was called away by a resident. In a separate incident, an unattended, open laptop displaying multiple residents' electronic health records was left visible in an area with several mobile residents present. The RN responsible admitted to leaving the laptop open by mistake. The Director of Nursing confirmed that protected health information is required to be secured at all times. Facility policy states that access to resident personal and medical records is limited to authorized staff and business associates.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection prevention and control protocols during multiple observed care activities. A registered nurse was observed dropping a resident's medication onto a report sheet, picking it up with ungloved hands, and administering it to the resident without discarding the contaminated pill. The nurse later acknowledged that gloves or a spoon should have been used and that the medication should not have been touched by hand. The Director of Nursing confirmed that the correct procedure would have been to discard the pill and obtain a new one. Additionally, staff did not perform appropriate hand hygiene during medication pass, as observed during the survey. Enhanced Barrier Precautions (EBP) were not utilized as required during wound care and catheter care for two residents. One resident with an indwelling catheter and an order for EBP was cared for by a CNA who did not wear a gown while draining the catheter, contrary to facility expectations. Another resident with a Stage 3 pressure ulcer and on EBP had a dressing change performed by an LPN who did not wear a gown or perform hand hygiene between glove changes. Furthermore, staff failed to disinfect a full body mechanical lift between uses with different residents, despite facility policy and DON expectations that lifts be sanitized between each resident. Staff interviews confirmed that lifts were only cleaned at the end of the day, not between residents.
Delay in Incontinence Care and Resident Dignity
Penalty
Summary
A resident with intact cognition and a history of anemia, hip fracture, muscle weakness, and incontinence requested assistance after wetting her pants. The resident, who required moderate to maximal assistance with personal care and was dependent with toileting, approached an LPN in the hallway and asked for help. The LPN informed the resident that a CNA would assist her but did not call for immediate help or provide assistance herself, instead continuing to administer medications to other residents. The resident repeated her request, but the LPN again deferred action, only activating the resident's call light and instructing the resident to wait in her room. The resident propelled herself to her room and waited. The LPN eventually asked the CNA to assist the resident when available, but the CNA prioritized other tasks and did not immediately respond. The CNA attended to other residents' needs before finally entering the resident's room to provide incontinence care approximately 13 minutes after the initial request. During this time, the resident expressed feeling bad and perceived that the nurse did not want to help her. The resident's care plan directed staff to provide incontinence care as needed, and facility policy required staff to treat residents with dignity and respect.
Failure to Include Target Behaviors and Non-Pharmacologic Interventions in Care Plan
Penalty
Summary
The facility failed to include psychotropic medication target behaviors and non-pharmacologic interventions in the care plan for one resident. Record review showed that the resident had diagnoses of anxiety, depression, and osteoarthritis, and was receiving antianxiety, antidepressant, and antipsychotic medications. The resident's Minimum Data Set (MDS) assessment indicated intact cognition, and the electronic health record (EHR) documented a range of behavioral issues, including physical and verbal aggression, socially inappropriate behaviors, and signs of anxiety and agitation. Progress notes and physician orders referenced the need to monitor the effectiveness of medications but did not specify target behaviors for staff to observe or document. The care plan, initiated upon admission, included the use of psychotropic medications but did not identify the specific target behaviors associated with the resident's conditions or outline non-pharmacological interventions for staff to implement. Staff interviews confirmed that the expectation was for care plans to include these elements. The facility's policy required comprehensive, person-centered care plans with measurable objectives, descriptions of services, and inclusion of recognized standards of practice, but these requirements were not met in this case.
Failure to Accurately Account for Controlled Medications and Maintain Proper Records
Penalty
Summary
The facility failed to maintain a consistent and accurate process for counting and accounting for controlled medications, resulting in a card of Oxycodone/acetaminophen (Percocet) prescribed to a resident becoming unaccounted for. The resident in question had a history of cerebral palsy, stroke, and polyneuropathy, and was receiving both scheduled and as-needed opioid medications for chronic pain. The care plan directed staff to administer analgesics as ordered by the physician. Despite these directives, staff were unable to account for a card of Percocet with 12 administrations remaining, as well as the associated controlled drug record sheet and the total count sheet for the medication cart. Multiple staff interviews revealed inconsistencies and confusion in the medication counting process. The DON confirmed that two cards of Percocet had been combined onto a single count sheet, contrary to facility expectations that each card should have its own record. On the day the discrepancy was discovered, staff noted that the count sheet and the partial card of Percocet were missing, and the count sheet for the cart was also unaccounted for. Staff involved in the medication counts provided conflicting accounts regarding the number of items in the cart and the process for cosigning count sheets. One staff member denied signing a count sheet for the Percocet, noting differences in ink and signature style, while another staff member was reported to have been defensive when questioned about the missing items and left the facility before the DON arrived. Further observations found that a discontinued controlled medication (Nayzilam) remained in the medication cart weeks after its discontinuation, and there was confusion among staff regarding how to count certain medications, such as whether a box of nasal spray should be counted as one or two items. The process for removing discontinued medications was not consistently followed, as staff were unaware that the medication was still present in the cart. These lapses in medication management and documentation contributed to the inability to account for controlled substances as required by professional standards.
Failure to Develop Timely and Complete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for one resident, as required by policy. The resident, who had intact cognition, was admitted with multiple diagnoses including anxiety, depression, contractures, joint pain, and osteoarthritis, and was prescribed several psychotropic and opioid medications. Documentation showed that the resident regularly received medication for chronic pain and anxiety, and her care plan was not initiated until several days after admission. The baseline care plan that was eventually created did not address the resident's chronic pain or psychotropic medication use, and it lacked a date and time of completion. Further review revealed that the baseline care plan was missing a signature and confirmation from the resident or her family, as required by facility policy. Staff interviews confirmed that the expected process was not followed, and progress notes did not document any confirmation of the care plan. The facility's policy required a baseline plan of care to be developed within 48 hours of admission to address immediate health and safety needs, but this was not completed for the resident in question.
Failure to Follow Physician's Order for Pressure Ulcer Intervention
Penalty
Summary
Staff failed to follow a physician's order for a resident with severe cognitive impairment, congestive heart failure, kidney disease, non-Alzheimer's dementia, and a right heel pressure ulcer. The physician's order and care plan both directed that Prevalon boots be applied at all times as tolerated, except when the resident was weight-bearing, to promote wound healing. Multiple observations on different occasions showed the resident was not wearing the Prevalon boots while in her wheelchair or in bed, and staff were unable to locate the boots in her room. Interviews with various staff members, including CNAs, a CMA, and an LPN, confirmed that the resident was non-weight bearing, required a mechanical lift for transfers, and had not refused care. Staff also indicated that the boots should have been on while the resident was in bed, in a wheelchair, or in a lift sling, and that there was no documentation or notification of refusal. The LPN was unaware the resident was not wearing the boots, and the DON stated the expectation was for this intervention to be included in the care plan rather than as a physician's order.
Failure to Provide Safe and Appropriate Respiratory Care and Accurate Documentation
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for two residents requiring oxygen therapy. For one resident with chronic obstructive pulmonary disease, observations revealed that oxygen tubing was not labeled or dated as required, and the resident reported the tubing had not been changed since admission. Staff interviews showed inconsistent understanding of when and how to change and label oxygen tubing, and the Director of Nursing confirmed the expectation for weekly changes with proper labeling, which was not met. For another resident with heart failure, respiratory failure, and obstructive sleep apnea, there was a lack of documentation in the care plan regarding the use of a Bi-pap machine, despite physician orders and the resident's need for the device. The Bi-pap machine was reported missing for an extended period, and the resident was not provided with the ordered therapy. Progress notes and treatment administration records contained discrepancies, with some staff documenting that the Bi-pap was provided when it was actually unavailable. The resident confirmed the machine had been missing and that he had not refused its use, while staff interviews corroborated the missing equipment and acknowledged inaccurate documentation. Facility policy required weekly changes and labeling of oxygen tubing, which was not consistently followed. The lack of proper respiratory equipment management, failure to provide ordered therapy, and inaccurate documentation contributed to the deficiencies identified for both residents.
Improper Handling and Documentation of Controlled Substances
Penalty
Summary
The facility failed to adhere to professional standards of practice by allowing Unit Managers/Supervisors, who were not licensed pharmacists, to draw up liquid Morphine and Lorazepam in 1 ml syringes. These syringes were then placed, both labeled and unlabeled, in medication carts for three residents. This practice was confirmed by a Licensed Practical Nurse (LPN) who observed nine unlabeled Morphine syringes in a medication cart. The Nurse Manager/Supervisor admitted to pre-drawing the liquid Morphine based on estimated usage over a 24-hour period, without proper labeling. Additionally, the facility failed to maintain accurate reconciliation and drug records for controlled substances. For one resident, the Controlled Drug Record form showed several open spaces where staff did not reconcile Pregabalin tablets, failing to count the medication with two staff members as required by policy. Similarly, for another resident, the Controlled Drug Record form revealed open spaces for Morphine Sulfate Solution and Fentanyl patches, indicating a failure to count these medications with two staff members on multiple occasions. The facility's policies on the storage and handling of medications were not followed. Medications were not stored in their original packaging, and containers with missing or incorrect labels were not returned to the pharmacy for proper labeling. The Controlled Substances policy required that controlled medications be counted at the end of each shift by the on-duty and off-duty nurses, with any discrepancies reported to the Director of Nursing (DON). However, these procedures were not consistently followed, leading to the deficiencies noted in the report.
Removal Plan
- Assessment of all medication carts and treatment carts for assurance all medications and treatment ointments/creams and etc. were appropriately labeled.
- Staff education on appropriate labeling and administration of narcotic and anti-anxiety medications.
- Medication administration education updates.
- Destruction of all liquid narcotic and anti-anxiety medications.
- Pain assessments on all residents completed.
- QAPI meeting conducted.
- Assurance of ongoing monitoring and review.
Failure to Respect Resident Dignity and Self-Determination
Penalty
Summary
The facility failed to honor residents' rights to dignity and self-determination, as evidenced by multiple incidents involving staff interactions with residents. One resident reported that a Certified Nursing Assistant (CNA) forced her to go to bed before she was ready and handled her roughly during care. Another resident described an incident where the same CNA was rude and disrespectful, slapping her on the belly and throwing her call light at her, which landed on her neck. This resident also witnessed the CNA transferring her roommate without the required lift device, despite the roommate's protests. Additionally, staff members were observed entering residents' rooms without waiting for an invitation after knocking, which startled the residents. A Licensed Practical Nurse (LPN) and an Activities staff member were both noted to have entered rooms uninvited, even during sensitive care procedures. Staff interviews confirmed that this was a common practice, with one CNA admitting to being guilty of this behavior herself. The facility's abuse policy, which emphasizes treating residents with respect and dignity, was not adhered to in these instances.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to maintain call lights within reach for four residents, as observed and confirmed through staff and resident interviews. During observations, call lights were found on the floor or hanging down the side of the bed, making them inaccessible to residents. For instance, one resident's call light was positioned on the floor, while another resident's call light was hanging down the side of the bed, preventing the resident from reaching it. Staff interviews confirmed these observations, with one staff member noting that call lights were sometimes hooked to light fixtures or curtains, and another staff member finding call lights under bedspreads. Residents also reported issues with call light accessibility. One resident confirmed that their call light was not always within reach, leading them to yell for assistance. Staff interviews further corroborated these findings, with multiple staff members acknowledging that call lights were often out of reach for residents. The facility's policy, revised in March 2018, directed staff to provide care and services to maintain residents' ability to carry out activities of daily living, which includes ensuring call lights are accessible.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for its residents, as evidenced by multiple observations and staff interviews. A photo taken on November 19th revealed dried and hard oatmeal, other food debris on a bedside stand, and dried food on the floor in a resident's room. Additionally, a brown stain consistent with a bowel movement was observed on the wall beside the resident's bed, and a metal tray under the bed contained a dried black substance resembling dried coffee or a loose bowel movement with a dead bug adhered to it. Staff interviews confirmed the presence of dried food in resident rooms and described the rooms as being in disarray. Furthermore, during facility tours, a persistent foul odor of urine was noted in the Terrace A and Generation C hallways on multiple occasions. Staff confirmed the presence of this odor in the Terrace and Generation neighborhoods. The facility's Safe Resident Handling/Transfers policy, which was not dated, indicated that lifts should be cleansed and disinfected according to the manufacturer's instructions after each resident's use, but the report does not confirm adherence to this policy.
Deficiencies in Resident Care and Hygiene Practices
Penalty
Summary
The facility failed to properly transfer a resident who required an assistive device, provide appropriate oral care for two residents, and groom a female resident's facial hair. Resident #18, diagnosed with Non-Alzheimer's Dementia and Venous Insufficiency, was dependent on staff for transfers using an assistive lift device. Despite this, a staff member was observed transferring the resident independently without the required device, causing the resident to cry out in distress. Interviews with staff confirmed that transfers were often conducted without the necessary equipment and assistance, particularly during busy times such as meal preparation. Additionally, the facility failed to maintain proper oral hygiene for two residents. Resident #11's denture cup contained a partial plate with a significant buildup of food particles, and Resident #4's toothbrush was found entangled with hair, indicating neglect in oral care. Furthermore, Resident #6, who required assistance with personal hygiene due to Multiple Sclerosis, was observed with noticeable facial hair, which she expressed a desire to have removed. The facility's policies on safe resident handling and activities of daily living were not adhered to, contributing to these deficiencies.
Deficiencies in Resident Assessment and Medication Administration
Penalty
Summary
The facility staff failed to properly assess and follow up on incidents involving residents, leading to deficiencies in care. Resident #8, who had severe cognitive impairments and was at risk for falls, fell in her room and sustained a hematoma on her forehead. Despite the facility's Falls Management System policy requiring follow-up assessments every shift for 72 hours post-fall, staff did not properly assess the resident on multiple shifts following the incident. Resident #5 was observed with a bandage on his left elbow, covering a skin tear with dried blood and yellow drainage. There was no treatment order documented for this injury, and the incident report was not initially found in the electronic medical record. The resident was unaware of how the injury occurred, and there was a lack of follow-up assessments documented for the skin tear. Additionally, the facility staff failed to administer medications as prescribed for Residents #2 and #17. Medications were administered outside the prescribed time frames, with some morning medications given in the afternoon. The facility's policy required medications to be administered in a safe and timely manner, but staff did not adhere to these guidelines, leading to further deficiencies in care.
Cockroach Infestation in Facility
Penalty
Summary
The facility failed to maintain a resident environment free of cockroaches, as evidenced by multiple observations and interviews. Staff members, including a CNA/CMA and housekeepers, reported seeing both dead and alive cockroaches throughout the facility, including on medication carts, in resident rooms, and even in a resident's bed. A family member also confirmed seeing a live cockroach in a resident's room. Photographic evidence showed numerous dead cockroaches in traps within a resident's room. These observations indicate a significant infestation problem within the facility. The facility's pest control measures, as documented in extermination invoices, included the use of broad-spectrum insecticides and traps. However, these measures were insufficient to control the infestation. The exterminator's manager noted that the pesticides used had a residual effect rather than a direct kill, which may not be effective in high infestation situations. The exterminator company had communicated with facility management about the need for increased services, but management indicated that corporate approval was required for such actions. The presence of cockroaches in resident sink drains was described as indicative of a severe infestation.
Failure to Implement Care Plan for Resident's Personal Hygiene
Penalty
Summary
The facility failed to implement a care plan for a resident who was dependent on staff for personal hygiene due to Multiple Sclerosis. The Minimum Data Set (MDS) assessment indicated that the resident required assistance with activities of daily living, including shaving. Despite the care plan specifying that the resident preferred one staff member to assist with personal hygiene, observations on two occasions revealed that the resident had 1/4 to 1/2 inch long whiskers on her chin. During an interview, the resident expressed her desire to have the whiskers shaved, indicating dissatisfaction with their presence. The facility's policy on Activities of Daily Living, revised in March 2018, directed staff to provide necessary services for residents unable to carry out ADLs independently, including grooming, in accordance with the plan of care.
Deficiency in Treatment Administration Documentation
Penalty
Summary
A deficiency was identified in the facility's treatment administration process for a resident with a physician's order for Ammonium Lactate Lotion 12% to be applied daily to their bilateral lower extremities for Xeroderma. On November 19, 2024, a Licensed Practical Nurse (LPN), Staff J, documented that the treatment was completed, although it was not performed. During an observation and interview on November 20, 2024, Staff J confirmed that the bandages on the resident's legs were dated November 18, 2024, indicating that the dressing change had not occurred as ordered. Staff J admitted to initialing the treatment order based on information from another LPN, Staff Q, who claimed to have performed the treatment. The facility's policy requires the individual administering medication to document it in the Electronic Medication Administration Record (EMAR) system after administration, ensuring the right resident, medication, dosage, time, and method are verified before administration.
Failure to Secure Medication Carts and Supervise High-Risk Resident
Penalty
Summary
The facility staff failed to maintain a locked and secured treatment cart and provide appropriate nursing supervision, leading to potential safety hazards. Observations revealed multiple instances where treatment and medication carts were left unlocked and unattended in various locations within the facility, including near the nurse's station and in the Terrace and Generation neighborhoods. Staff interviews confirmed that unlocked and unattended carts were a recurring issue, which is contrary to the facility's policy that requires medication carts to be kept closed and locked when out of sight of the nurse or Certified Medication Aide (CMA). Additionally, the facility failed to provide adequate supervision for a resident with severe cognitive impairments and a high risk of falls. The resident, who had diagnoses including Non-Alzheimer's Dementia and muscle weakness, was dependent on staff for transfers and mobility. Despite being identified as a fall risk, the resident was left unattended in her room in a specialized wheelchair, leading to a fall that resulted in a hematoma on her forehead. Staff interviews confirmed that the resident should not have been left unattended, highlighting a lapse in supervision and adherence to the care plan designed to prevent falls.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to properly label and store liquid Morphine and Lorazepam, which are narcotic and anti-anxiety medications, respectively, for three residents. During an observation, it was found that nine unlabeled Morphine syringes were stored in a medication cart. Staff I, an LPN, confirmed that Nurse Managers and Supervisors had been drawing up these medications in unlabeled syringes for two months. Staff A, an LPN/Nurse Manager/Supervisor, admitted to pre-drawing the liquid Morphine based on estimated usage over a 24-hour period, without labeling the syringes. The Interim Director of Nursing (DON) confirmed that the practice of pre-drawing and not labeling the medications had been ongoing since before December 2023. Staff J, an LPN, expressed frustration with this practice and had communicated her concerns to Staff A. Additionally, Staff C, a CNA/CMA, and Staff G, an LPN, confirmed they administered these pre-drawn, unlabeled medications to residents. The facility's policy required that only a pharmacist could pre-set up liquid narcotics and anti-anxiety medications, which was not adhered to in this case. Further investigation revealed that a bottle of liquid Morphine was found in Staff A's office without a Controlled Drug Record form, and it was not dated when opened. The facility's policies on medication storage and controlled substances were not followed, as the medications were not stored in their original containers, and there was a lack of proper labeling and documentation. Staff I and Staff J both confirmed that the practice of pre-drawing and not labeling medications was not acceptable and had been a concern since they began their employment.
Infection Control Lapses in PPE Usage and Catheter Management
Penalty
Summary
The facility staff failed to adhere to proper infection prevention and control protocols by not donning Personal Protective Equipment (PPE) while providing direct care to residents with catheters, PICC lines, and open skin treatments. Specifically, a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) were observed not wearing gowns while performing procedures on residents with PICC lines and supra pubic catheters, despite signage indicating the need for enhanced barrier precautions. The RN was seen handling a PICC line without a gown, and the LPN failed to cleanse a catheter port with alcohol before reconnecting it, subsequently touching the resident's skin and bedding with contaminated gloves. Additionally, the facility staff did not maintain proper catheter tubing placement, as evidenced by a photo showing a resident's catheter tubing positioned directly on the floor. Interviews with staff confirmed that some personnel did not consistently don PPE during care involving catheters and PICC lines. These observations and interviews highlight lapses in infection control practices, potentially compromising resident safety.
Failure to Assess and Document Post-Fall Care
Penalty
Summary
The facility failed to provide necessary assessments and interventions for a resident following a fall and prior to transferring the resident to a higher level of care. The resident, who had intact cognition and multiple diagnoses including atrial fibrillation, end-stage renal disease, and hemiplegia, experienced a fall while being transferred from a wheelchair to bed using a sliding board. The incident report noted that the resident lost balance and slid to the floor, but no injuries were observed at the time. Vital signs were within normal limits, and the resident was assisted back into the wheelchair by two staff members. Despite the fall, the facility's progress notes lacked follow-up documentation regarding the fall or the decision to send the resident to the hospital for evaluation. The resident was later returned to the facility from the hospital without any documented assessment or intervention related to the fall. The care plan for the resident included interventions for fall risk and assistance with transfers, but there was no evidence of these being effectively implemented or documented following the incident. The Interim Director of Nursing stated that it was expected for staff to complete an assessment for pain and injury after a fall and document findings every shift for 72 hours. However, this was not done in the case of the resident. The facility's policies on changes in a resident's condition and falls management required documentation of any changes and follow-up assessments, which were not adhered to in this instance.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate treatment and services to promote the healing of a pressure ulcer for a resident, identified as Resident #1. The resident was admitted with a left heel blister measuring 3.5 cm x 3 cm, which was noted on admission but not addressed in the care plan until ten days later. The facility did not initiate treatment for the blister until five days after admission, and the required weekly skin assessments were not completed as ordered. Additionally, the Braden Scale for Predicting Pressure Sore Risk was not conducted on admission or weekly as required, with only one assessment completed on September 21, 2024. Resident #1 had a complex medical history, including atrial fibrillation, end-stage renal disease, diabetes mellitus, seizure disorder, and hemiplegia, which increased the risk for skin breakdown. The resident required substantial assistance for personal care and was dependent on staff for transfers and toileting. Despite these risk factors, the facility did not adhere to its own protocols for skin assessments and treatment, leading to a necrotic area developing on the resident's left heel. The facility's policy on pressure injury surveillance required licensed nurses to assess residents and report changes in condition to physicians and management staff. However, the facility did not follow these protocols, as evidenced by the lack of timely assessments and treatment for the resident's pressure ulcer. The Interim Director of Nursing acknowledged that the facility's expectations for skin assessments and Braden Scale evaluations were not met, contributing to the deficiency in care for Resident #1.
Failure to Adhere to Transfer Protocols Leads to Resident Fall
Penalty
Summary
The facility failed to provide a safe transfer for a resident, resulting in a fall. The resident, who had intact cognition and multiple medical conditions including hemiplegia and non-weight bearing status on the left lower extremity, required two staff members for transfers using a sliding board as per the care plan. However, during a transfer from a wheelchair to a bed, only one staff member was present, leading to the resident losing balance and sliding to the floor. The incident occurred when a Certified Nursing Assistant (CNA) attempted to assist the resident with the transfer. Despite being aware that the transfer required two staff members, the CNA proceeded with the transfer alone after the resident indicated they could manage it together. The resident subsequently lost balance and fell, although no injuries were reported. The Licensed Practical Nurse (LPN) who responded to the call light confirmed that only one staff member was present during the transfer. Interviews with staff revealed that the CNA was aware of the two-person requirement but did not adhere to it, influenced by the resident's assertion of independence. The facility's policy and care plan clearly stated the need for two staff members for such transfers, but this was not followed, leading to the fall. The incident highlights a failure to adhere to established care plans and protocols, resulting in an unsafe transfer situation.
Failure to Follow Physician Orders for Catheter Care
Penalty
Summary
The facility failed to follow physician orders for catheter care for two residents. The first resident, with a BIMS score indicating intact cognition, required maximum assistance for toileting and was dependent on two-person assistance for bed mobility and transfers. The resident had an indwelling catheter and was always incontinent of bowel. The care plan directed catheter changes as ordered, but the electronic medication administration record (eMAR) lacked documentation on when the catheter was to be changed. An observation revealed a discrepancy in the catheter size, and the interim Director of Nursing (DON) acknowledged the lack of proper documentation and was unaware of the reason for the incorrect catheter size. The second resident, also with intact cognition, required maximum assistance for toileting and had an indwelling catheter. The care plan specified catheter changes as ordered, but the eMAR showed the last documented catheter change was over a month prior, contrary to the physician's order for monthly changes. An observation revealed a different catheter size than ordered, and the interim DON, who had recently joined the facility, was unaware of why the catheter had not been changed according to the schedule or why the incorrect size was used. Facility policies emphasized adherence to physician orders and proper catheter care, but these were not followed in these instances.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect, as evidenced by an incident involving a male staff member who allegedly handled the resident roughly during a transfer to bed. The resident, who had moderate cognitive impairment and required assistance with activities of daily living due to a self-care deficit, reported feeling anxious and afraid of the staff member. The resident's family member and a family friend both observed bruising on the resident's ankles, which they attributed to the rough handling by the staff member. The incident was reported to the facility by the resident's family member, who was informed that the staff member would no longer provide care for the resident. However, the facility did not conduct a thorough investigation, as they did not interview the staff member involved or report the incident to the Department of Inspections and Appeals and Licensing (DIAL). The facility's internal documentation was limited to a grievance form, which noted that the staff member was educated on being cautious during transfers but did not include any disciplinary action. Interviews with the resident, family member, family friend, and staff revealed inconsistencies in the facility's handling of the incident. The resident consistently reported feeling anxious and afraid of the staff member, while the staff member denied being rough and stated he was only in a hurry due to another resident's potential fall. The facility's failure to adequately address the resident's concerns and ensure her dignity and respect constitutes a deficiency in care.
Inconsistent Code Status Documentation
Penalty
Summary
The facility failed to ensure congruence between the Iowa Physician's for Scope of Treatment (IPOST) and the Care Plan regarding the code status for a resident. The resident had a Do Not Resuscitate (DNR) order documented in the physician's orders and the IPOST form. However, the Care Plan indicated that the resident and their responsible party requested a cardiopulmonary resuscitation (CPR)/full code status, which was to be honored until the next review. The facility's policy on Advanced Directives required that any changes or revocations be communicated to the care plan team to update the care plan accordingly. Despite this policy, the discrepancy between the IPOST and the Care Plan was not addressed, as acknowledged by the Administrator during interviews. The staff typically referred to the IPOST for code status, leading to the inconsistency in the resident's documented wishes.
Failure to Report Alleged Abuse and Inadequate Investigation
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident with moderate cognitive impairment, who had a history of hip and knee replacement, cancer, multiple sclerosis, and glaucoma. The incident involved a male staff member who allegedly handled the resident roughly during a transfer, resulting in bruising on the resident's ankles. Despite the family member's report to the facility, the alleged abuser continued to work with residents, including the affected resident. The facility's internal investigation was inadequate, as they did not interview the staff member involved or document the investigation findings properly. The Social Services Director (SSD) and the Director of Nursing (DON) observed the resident and noted bruising on the resident's toe, which the resident attributed to dropping a cell phone. However, the resident and a family friend reported bruising on the ankles, which they believed was caused by the staff member's rough handling. The facility did not report the incident to the State survey and certification agency, as they concluded it was not abuse. Interviews with the resident, family member, and family friend revealed consistent accounts of the staff member's rough handling and the resident's fear of the staff member. The facility's policy required immediate investigation and documentation of such incidents, but the facility failed to comply with these procedures. The staff member continued to work in the facility without any disciplinary action, and the facility did not ensure the resident's safety by preventing further contact with the alleged abuser.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to initiate and complete a thorough investigation of alleged abuse involving a resident with moderate cognitive impairment and multiple medical conditions, including hip and knee replacement, cancer, multiple sclerosis, and glaucoma. The incident involved a male staff member allegedly handling the resident roughly during a transfer to bed, resulting in bruising on the resident's ankles. The family member reported the incident to the facility, and the Social Services Director (SSD) was informed. However, the facility did not conduct a comprehensive investigation, as they did not interview the staff member involved or document the investigation findings adequately. The SSD and the Director of Nursing (DON) both interacted with the resident and observed bruising on her toe, which the resident attributed to dropping her cell phone. The resident expressed anxiety and fear regarding the staff member's actions, describing him as rough and causing injuries. Despite these concerns, the facility did not report the incident to the Department of Inspections and Appeals and Licensing (DIAL) as they did not consider it abuse after their limited investigation. The staff member continued to work at the facility and provide care to the resident. The facility's grievance form documented the family's concerns and the SSD's interview with the resident. However, the investigation was not thorough, as the facility did not take disciplinary action against the staff member or ensure he would not provide care to the resident again. The facility's policy on abuse and neglect prevention requires immediate initiation of an investigation and documentation of findings, which was not adequately followed in this case.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Long Term Care Ombudsman of the discharge/transfer of a resident as required by federal regulation. Specifically, the clinical record for a resident who was discharged to the hospital on December 25, 2023, and reentered the facility on December 29, 2023, lacked documentation of notification to the LTC Ombudsman. During an interview, the Administrator confirmed that the facility had not notified the Ombudsman when the resident was discharged to the hospital. The facility's policy on Transfer and Discharge, with a copyright date of 2023, requires that notice be provided to the LTC Ombudsman as soon as practicable before the transfer or discharge, and that evidence of the notice being sent should be maintained.
Failure to Conduct Level II PASARR Evaluation for Resident with PTSD
Penalty
Summary
The facility failed to refer a resident with a Level I Preadmission Screening and Resident Review (PASARR) for a Level II PASARR evaluation despite the resident having a diagnosed serious mental disorder. The resident, who was admitted with a diagnosis of PTSD, was not referred for a Level II PASARR evaluation when this diagnosis was known to the facility. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and documented diagnoses including major depressive disorder and PTSD. Despite these diagnoses, the facility did not complete a Level II PASARR, as the initial Level I PASARR did not indicate a need for further evaluation. The facility's administrator acknowledged that there was no specific policy in place for PASARR completion, although the facility followed general guidelines. The responsibility for ensuring PASARR completion was assigned to a part-time social worker. The failure to submit a Level II PASARR was identified during a review of the resident's electronic health records, which showed the PTSD diagnosis was present upon admission. The facility's oversight in not conducting a Level II PASARR evaluation for the resident with a serious mental disorder constitutes the deficiency noted in the report.
Failure to Implement Comprehensive Care Plan for Urostomy Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a urostomy and urostomy bag. The resident, who is cognitively intact and has diagnoses including neurogenic bladder and paraplegia, was admitted with a urostomy tube. The care plan did not include instructions on the care of the urostomy bag or monitoring and documenting intake and output. The resident reported that staff did not empty the bag frequently, leading to it becoming very full, with staff emptying it only once a day when it was very full. The Director of Nursing (DON) confirmed that the care plan lacked instructions for urostomy bag care and acknowledged that the bag should be emptied at least once per shift, ideally three times a day, with output documented. However, a review of the electronic health record showed inconsistent documentation of the bag being emptied, with several days lacking entries. The DON stated that while staff were expected to complete and document this task, it was not being consistently monitored or documented. The facility's policy requires the interdisciplinary team to develop and implement a comprehensive, person-centered care plan, which was not adhered to in this case.
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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