Savannah Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Pleasant, Iowa.
- Location
- 601 S Prairie Street, Mount Pleasant, Iowa 52641
- CMS Provider Number
- 165592
- Inspections on file
- 18
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Savannah Heights during CMS and state inspections, most recent first.
The deficiency centers on the facility’s failure to maintain effective fall‑prevention measures and functioning chair/bed alarms for several residents with varying levels of cognitive impairment and mobility needs. One resident with intact cognition experienced multiple falls from bed while sitting or attempting to get up, with incident reports and the care plan lacking new or revised interventions. Another resident with dementia, TBI, and a history of falls had numerous falls in the room, hallway, and country kitchen, often during self‑transfers or attempts to walk without devices, yet the care plan was not updated with additional, specific interventions despite a provider order to monitor behaviors related to self‑transfers and alarms. A third resident with severe cognitive impairment and documented alarm use had falls where the chair or bed alarm did not sound, even though it was plugged in, and staff acknowledged that one alarm type had delayed or absent activation. Interviews with the MDS coordinator, DON, ADON, LPNs, and CNAs showed inconsistent post‑fall assessment, reliance on re‑education, lack of formal root cause analysis, uncertainty about who updates care plans, and incomplete documentation of fall interventions, all contributing to inadequate supervision and unaddressed accident hazards.
A resident who was dependent on staff for transfers and toileting due to COPD and fall risk had her bedside commode left unemptied after use on multiple occasions. Several CNAs observed the commode containing urine and feces at the start of their shifts, with inconsistent reporting to nursing or administration. The DON and Administrator were unaware of the issue, despite facility policy requiring prompt cleaning to maintain resident dignity.
A facility failed to ensure that a resident with moderately impaired cognition could safely self-administer medications. The resident's care plan noted impaired thought processes, yet a bottle of chlorhexidine gluconate solution was found accessible in the bathroom. The clinical record lacked documentation of the resident's ability to self-administer safely, and the acting DON admitted the mouthwash should have been secured. The Administrator could not find a policy on self-administration of medications.
A facility failed to document non-pharmacological interventions before administering PRN anxiolytics to a resident with anxiety, chronic pain, and hypertension. Despite a policy requiring such documentation, the Care Plan did not include directives for these interventions, and the Medication Administration Records lacked evidence of attempts prior to medication administration. Interviews confirmed staff were expected to document interventions, but this was not reflected in practice.
A resident with intact cognition required assistance with ADLs, and the facility failed to respond to their call lights within the 15-minute policy timeframe. The All Alarms Report showed multiple instances of delayed responses, ranging from 17 to 41 minutes. The resident reported timing the responses and noted a 20-minute delay when needing bathroom assistance. The facility's administrator confirmed the expectation for staff to respond within 15 minutes.
A facility failed to document non-pharmacological interventions before administering PRN anxiolytics to a resident with anxiety, chronic pain, and hypertension. The resident's Care Plan did not address anxiolytic use or instruct staff to attempt non-pharmacological interventions first. Despite facility policy, there was no documentation of such interventions, confirmed by staff interviews.
The facility failed to offer the pneumococcal vaccine at the recommended times for two residents. Immunization records showed that the residents received the PCV13 and PPSV23 vaccines, but there was no documentation of the facility offering the vaccine as per guidelines. The Administrator noted a discrepancy in the Iowa Immunization Registry, which contributed to the oversight.
A resident with severe cognitive impairment experienced an unwitnessed fall, and the facility failed to complete the required neurological assessments. Despite the resident denying pain or hitting her head, multiple neuro checks were missed. Staff interviews revealed that the assessments were not conducted due to the resident being at meals or staff assuming they were unnecessary. The facility's policy required frequent neuro assessments for at least 72 hours following an unwitnessed fall.
A resident with severe cognitive impairment and a history of falls was left unsupervised in her room in a wheelchair, contrary to her care plan. She attempted to transfer herself to the toilet and fell, although no injuries were reported. Staff interviews and facility policies confirmed that the resident should not have been left alone in her room.
Failure to Maintain Effective Fall Prevention and Functioning Alarms for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the environment was free from accident hazards and that residents received adequate supervision and effective fall-prevention interventions, including properly functioning chair/bed alarms. For one resident with intact cognition who used a wheelchair and walker and was independent with mobility, multiple falls were documented over a short period. Nursing notes described repeated episodes of this resident sliding or rolling from the bed to the floor, often while sitting or lying on the edge of the bed, reaching for items, or attempting to get up. These falls resulted in bruises, lacerations, and reopened scabs. Incident reports for these falls lacked documentation of new or revised interventions, and the resident’s care plan did not reflect the repeated falls or any updated fall-prevention strategies beyond prior education not to sit on the side of the bed. Another resident with moderately impaired cognition, a history of stroke, non‑Alzheimer’s dementia, TBI, and multiple prior falls was care planned for fall risk with general interventions such as anticipating needs, ensuring call light access, and appropriate footwear, later adding that the resident could be taken near the nurse station for more supervision. Despite this, numerous falls were documented in various locations, including the hallway, resident room, in front of the closet, in the country kitchen, and near recliners and wheelchairs. Several falls involved self‑transfers, attempts to walk without assistive devices, or attempts to move between chairs and wheelchairs, sometimes associated with seizures or raising the bed to an unsafe height and turning up the TV volume so that alarms could not be heard. Nursing notes repeatedly described the resident being found on the floor, sometimes with lacerations, hematomas, or scattered bruising from numerous falls. The care plan did not show new or revised interventions corresponding to these repeated falls, even though a physician order required documentation of behaviors related to self‑transfers and alarm use. A third resident with severely impaired cognition, gait/balance problems, and multiple psychotropic and insulin medications was care planned for fall risk with an intervention to ensure alarms were in place and functioning properly, supported by a physician order to check alarms four times daily. This resident experienced falls where she was found sitting on the floor next to the bed or after ambulating independently and hitting her head on the bedstand, resulting in a laceration. An incident report documented that the resident’s chair alarm was not going off at the time of one fall, and another nursing note stated that the bed alarm was plugged in and working but did not sound when the resident was found on the floor with emesis present. Staff interviews revealed that one type of alarm box had a delayed response or sometimes did not go off, and that the DON was aware of issues with certain alarm units. Interviews with the MDS coordinator, DON, ADON, LPNs, and CNAs showed that post‑fall interventions were often limited to re‑education, that care plans were not consistently or promptly updated after falls, that root cause analyses were not formally documented, and that staff were uncertain about where fall interventions were documented and who was responsible for updating care plans. These actions and inactions contributed to the failure to ensure effective supervision, functioning alarms, and timely, resident‑specific interventions to prevent recurrent falls for the residents reviewed.
Failure to Maintain Resident Dignity by Not Emptying Bedside Commode
Penalty
Summary
Staff interviews, record review, and facility policy revealed that the facility failed to maintain resident dignity by not emptying a bedside commode after providing toileting assistance for a resident who was dependent on staff for transfers and toileting hygiene. The resident, who had intact cognition and required a mechanical lift with two staff for transfers due to chronic obstructive pulmonary disease (COPD) and fall risk, was found to have her bedside commode left unemptied on multiple occasions. Several CNAs reported noticing the commode containing urine and feces when starting their shifts, with some stating they had informed nurses about the issue, while others did not report it due to previous inaction. The resident was aware of the situation and commented on it to staff. The Director of Nursing (DON) and Administrator were unaware of the issue, as staff had not consistently reported it to them. The facility's policy requires that residents be treated with respect and dignity, and that the environment should promote quality of life. Despite this, the commode was not promptly emptied and cleaned after use, as expected by facility policy and as stated by the DON. The failure to empty the commode after use was confirmed by multiple staff members and was not addressed in a timely manner, resulting in a lack of dignified care for the resident.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that only residents capable of safely self-administering medications had access to them. This deficiency was identified for one resident who had a history of traumatic brain dysfunction, anxiety, and morbid obesity, with a BIMS score indicating moderately impaired cognition. The resident's care plan noted impaired thought processes due to a traumatic brain injury. Despite this, a bottle of chlorhexidine gluconate solution, prescribed as a medicated oral rinse, was observed on the sink in the resident's bathroom, accessible to the resident. The clinical record lacked documentation confirming the resident's ability to self-administer medications safely. The acting DON acknowledged that the mouthwash should have been secured in a lock box and suggested it was left out by staff after use. Additionally, the facility's Administrator could not locate a policy regarding the self-administration of medications.
Failure to Document Non-Pharmacological Interventions for Anxiolytic Use
Penalty
Summary
The facility failed to address the use of anxiolytics on the Care Plan for a resident diagnosed with generalized anxiety disorder, chronic pain, and hypertension. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. Despite having a policy that required documentation of non-pharmacological interventions prior to administering PRN (as needed) medications, the facility did not document such interventions before administering lorazepam, an anxiolytic, to the resident on multiple occasions in July 2024. The Care Plan, as of late August 2024, did not include directives for staff to attempt non-pharmacological interventions before administering PRN anxiolytics. Interviews with the facility's Administrator and a Registered Nurse (RN) revealed that staff were expected to document three non-pharmacological interventions prior to administering an anxiolytic, but this was not reflected in the resident's Care Plan or the Medication Administration Records (MARs). The facility's failure to document these interventions and update the Care Plan contributed to the deficiency identified during the survey.
Delayed Call Light Response for a Resident
Penalty
Summary
The facility failed to respond to call lights in a timely manner for one resident, identified as Resident #135, who was reviewed for staffing concerns. The resident, who had intact cognition with a BIMS score of 15 out of 15, required assistance with activities of daily living as noted in their care plan. The facility's All Alarms Report for the period from August 21 to August 28, 2024, showed multiple instances where the call light response times for this resident exceeded the facility's policy of responding within 15 minutes. Specific instances included response times ranging from 17 to 41 minutes. On August 26, 2024, the resident reported that it took staff 20 minutes to respond when they needed to use the bathroom. The resident also mentioned timing the staff's response using a clock on the wall. The facility's administrator acknowledged that staff should respond to call lights as close to 15 minutes as possible, according to the facility's undated policy on answering call lights.
Failure to Document Non-Pharmacological Interventions Before PRN Anxiolytics
Penalty
Summary
The facility failed to document non-pharmacological interventions prior to administering PRN anxiolytics to a resident with generalized anxiety disorder, chronic pain, and hypertension. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15. The Medication Administration Records (MAR) for July and August 2024 showed multiple administrations of lorazepam, an anxiolytic, without documentation of attempted non-pharmacological interventions. The resident's Care Plan did not address the use of anxiolytics or instruct staff to attempt non-pharmacological interventions before administering PRN anxiolytics. Despite the facility's policy requiring documentation of such interventions, including relaxation, repositioning, and food/beverages, there was no evidence of these steps being documented. Interviews with the Administrator and a Registered Nurse confirmed that staff were expected to document three non-pharmacological interventions prior to administering PRN anxiolytics, which was not done in this case.
Failure to Offer Pneumococcal Vaccine at Recommended Times
Penalty
Summary
The facility failed to offer the pneumococcal vaccine at the recommended times for two residents, as identified during a clinical record review. Resident #26's immunization record indicated that they received the PCV13 vaccine in 2016 and the PPSV23 vaccine in 2012. Similarly, Resident #13's record showed they received the PCV13 vaccine in 2018 and the PPSV23 vaccine in 2010. However, there was no documentation to confirm that the facility offered the pneumococcal vaccine to these residents as per the recommended guidelines. The facility's policy, reviewed in February 2024, stated that residents would be offered the pneumococcal vaccine upon admission, following current CDC or Iowa Department of Public Health guidelines. During an interview, the Administrator acknowledged a discrepancy in the Iowa Immunization Registry Information System (IRIS), which listed two pneumococcal vaccinations for the same date for both residents, leading to an incorrect assumption of series completion. This oversight contributed to the failure in offering the vaccine as required.
Failure to Complete Neurological Assessments After Unwitnessed Fall
Penalty
Summary
The facility failed to complete the required neurological assessments following an unwitnessed fall for a resident with severe cognitive impairment. The resident, who had a history of unspecified dementia and anxiety, fell in her room while attempting to transfer herself to the toilet. Although the resident was found laughing and denied pain or hitting her head, the facility's protocol required neuro assessments to be initiated due to the unwitnessed nature of the fall and the resident's low BIMS score. The neuro assessments were not completed as required. Documentation revealed multiple missed checks, including 15-minute, 30-minute, hourly, and 4-hour checks. Staff interviews indicated that the assessments were not conducted because the resident was at meals or because staff believed the assessments were unnecessary since the resident did not exhibit signs of head injury. The LPNs involved admitted to not performing the checks due to being occupied with other tasks or assuming fewer checks were needed. The facility's policy mandated frequent neurological assessments for at least 72 hours following an unwitnessed fall, regardless of whether the resident showed immediate signs of head injury. The Director of Nursing confirmed that the neuro assessments were not completed as required and stated that the assessments should be offered to residents even if they are at meals, with abnormal results reported to the provider. The failure to adhere to this protocol represents a significant deficiency in the care provided to the resident.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with severe cognitive impairment, resulting in a fall. The resident, who had a history of dementia and was at moderate risk for falls, was left unsupervised in her room while in a wheelchair. Despite the care plan specifying that the resident should not be left alone in her wheelchair in her room and should be transferred to her bed or recliner, staff did not adhere to these guidelines. The resident attempted to transfer herself to the toilet, resulting in a fall, although no injuries were reported. The incident occurred when the resident moved herself from a common area to her room without staff assistance. The resident's door was closed, and she was found on the floor by a CNA with the alarm sounding. The resident was laughing and did not report any pain or injuries. The facility's policy required staff to check on residents every two hours, but the resident was left unattended for a period exceeding this timeframe. Interviews with staff and the Director of Nursing confirmed that the resident should not have been left alone in her room in a wheelchair. The facility's fall risk policy and care planning policy were not followed, leading to the resident's fall. The staff's failure to adhere to the care plan and supervision requirements directly contributed to the incident.
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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