Spencer Post Acute Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Spencer, Iowa.
- Location
- 711 West 11th Street, Spencer, Iowa 51301
- CMS Provider Number
- 165449
- Inspections on file
- 21
- Latest survey
- March 30, 2026
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Spencer Post Acute Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
The facility did not provide or document required bed hold notifications for residents transferred to the hospital for acute medical issues, including those with cognitive impairment, stroke, respiratory failure, and other serious conditions. Staff interviews and record reviews confirmed that bed hold forms were missing from the medical records, and the notifications were not completed at the time of transfer, contrary to facility policy.
Surveyors observed that staff failed to follow infection prevention protocols, including hand hygiene, proper cleaning of shared medical equipment, and use of PPE during care for residents with wounds, catheters, and enteral tubes on Enhanced Barrier Precautions. Staff used a blood glucose monitor on multiple residents without proper disinfection and did not consistently wear PPE during high-contact care activities, despite facility policies and CDC guidelines requiring these measures.
A resident was unable to access personal funds during weekends and was told to wait for the office manager, while staff and management interviews revealed no process or policy for providing funds outside business hours, resulting in a lack of reasonable access to personal funds.
Two residents prescribed high-risk medications did not have care plans that included required non-pharmacological interventions or targeted behaviors for monitoring. One resident's care plan lacked details for antipsychotic, psychotropic, and opioid medication management, while another resident's record did not show evidence of a required Gradual Dose Reduction for an antidepressant, despite repeated pharmacy requests.
A resident with anemia, cancer, and malnutrition was observed using oxygen, but the care plan, physician orders, and MAR did not reflect an order for oxygen therapy following a hospital discharge. Interviews with the ADON and DON confirmed the omission, which was not in accordance with facility policy requiring timely care plan updates.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to follow the established care plan.
A resident with severe cognitive impairment and multiple medical conditions experienced significant weight loss over one month, but staff did not promptly identify or assess the change as required by facility policy. Although the care plan called for daily monitoring and regular weight checks, the necessary evaluation and intervention were delayed, and staff did not immediately obtain a reweight or initiate further assessment.
A resident with anemia, cancer, and malnutrition, who was cognitively intact, received medications via a feeding tube despite being able to take them orally. An RN failed to check tube placement before administering medications, pushed medications quickly through the tube, and left medication residue in the cup and syringe. Staff interviews and facility policy confirmed that tube placement should be checked prior to administration and medications should not be pushed rapidly.
A resident with severe cognitive impairment and end stage renal disease did not have consistent documentation of pre- and post-dialysis vital signs, and there was no record of communication with the physician regarding a fluid restriction. Facility policy required collection of dialysis run sheets and follow-up, but these were missing for multiple dialysis sessions, as confirmed by staff.
A medication error rate above 5% was found when a nurse failed to prime insulin pens before administering insulin to a resident with diabetes and severe cognitive impairment. The RN stated she had never been told to prime the pens, contrary to facility expectations, resulting in two medication errors during the observed medication pass.
Two residents experienced significant medication errors: one received insulin injections without proper priming of the insulin pen by an RN, and another had a prescribed anticonvulsant dose omitted by an LPN, contrary to facility policy. These errors were identified through observation, record review, and staff interviews.
During a lunch meal service, staff used a 3 oz scoop instead of the required 4 oz scoop to serve peas to 22 residents on regular diets, resulting in the failure to follow the prescribed menu and portion sizes as outlined in facility policy.
Two residents experienced deficiencies in medical record accuracy when physician orders were not properly transcribed into the EHR. One resident's MAR did not match the medication packaging or hospital discharge instructions for potassium chloride, and another resident was observed using oxygen without any corresponding orders or care plan documentation. Staff confirmed these discrepancies, and facility policy for recording orders was not followed.
A resident who was cognitively intact had previously received PCV13 and PPSV23 vaccines, but there was no documentation that the resident was educated about, offered, or provided the opportunity to consent to or refuse the recommended PCV20 or PVC21 vaccination, as required by CDC guidelines and facility policy.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in care. A resident on diuretics lacked a care plan for medication management, another with CHF had no updated care plan post-hospitalization, and a hospice resident's care plan lacked essential details. Additionally, a resident requiring eating assistance was left unsupervised, contrary to their care plan.
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Observations and interviews revealed that call lights were not answered promptly for several residents, with delays ranging from 15 minutes to over an hour. The facility's policy requires call lights to be answered within a reasonable time, with the expectation set at 15 minutes, though the DON preferred a 5-minute response time. Staff was observed responding to call lights but was unsure of the facility's expectations for response times.
The facility did not post the daily census sheet, which includes resident census and nurse working hours, as required. An LPN found that the census sheet for the current day had not been completed, and previous sheets were stored in the medication room. The Administrator confirmed that the charge nurse should initiate the posting at the start of the day shift.
The facility failed to maintain sanitary practices, with observations of unclean ice makers and improper food handling. Staff were seen transporting milk without a lid, mishandling salt and pepper packets, and failing to change gloves or wash hands after touching non-food surfaces. These actions violated the facility's Food Safety and Sanitation policy.
The facility failed to follow proper infection control practices, including transporting uncovered linen carts, inadequate hand hygiene between resident contacts, and improper disinfection of contaminated equipment. A resident with an indwelling catheter and specific diagnoses required enhanced precautions, which were not followed. The DON confirmed the facility's expectations, but staff did not adhere to policies on hand washing and sanitizing wipes.
The facility failed to provide a call light within reach for a resident under contact precautions and did not address maintenance issues for another resident with a malfunctioning closet door. A resident with moderate cognitive impairment was unable to access their call light, contrary to facility policy. Another resident with severely impaired cognition had a closet door off its track and a misplaced toilet safety rail, with the Maintenance Supervisor unaware of these issues due to inconsistent reporting processes.
A facility failed to include a resident's psychotropic medication in the baseline care plan within 48 hours of admission, as required by policy. The resident, with intact cognition and multiple diagnoses including depression, was taking duloxetine as per the hospital discharge list. The omission was confirmed by the MDS Coordinator and acknowledged by the DON.
A resident's care plan was not updated after the discontinuation of mirtazapine, an antidepressant medication, despite facility policy requiring such updates. The MDS Coordinator admitted that the care plan should have been revised to reflect the medication change, highlighting a lapse in maintaining accurate care plans.
A resident's weight monitoring was not conducted as per physician orders, with discrepancies found between the MAR and EHR. The resident reported being weighed only once, while the MAR indicated multiple entries. An LPN claimed to have entered weights in the EHR, but they were missing, violating facility policy on accurate documentation.
A facility failed to provide a Restorative Exercise Program for a resident with severe cognitive impairment and functional limitations in range of motion. The resident was dependent on staff for daily activities and had contractures in both arms. The initial care plan included a directive for a Restorative Exercise Program, but the current care plan did not. The facility had discontinued all restorative programs following a prior deficiency, and no restorative staff were employed at the time.
The facility failed to attempt Gradual Dose Reductions (GDR) for two residents on psychotropic medications. One resident, with non-Alzheimer's dementia and depression, had their antidepressant reduced but not discontinued despite no symptoms. Another resident with severe cognitive impairment was on mirtazapine and escitalopram without documented GDR attempts. The DON cited difficulties in record organization due to a transition to electronic files and ownership change.
A resident with multiple health conditions, including renal disease, was not served the correct therapeutic diet as prescribed. Instead of the renal diet, the resident received regular diet items, including carrots, which were not on the menu. The facility's policy to ensure the correct tray is served was not followed, and a dietary aide confirmed that carrots were used as a substitution due to the unavailability of green beans.
A resident with a documented request for CPR was found unresponsive with no pulse or respirations. Despite the resident's full code status, the LPN and RN on duty did not initiate CPR. The LPN failed to check the resident's code status and left the room without performing resuscitation efforts. The RN confirmed the absence of vital signs but did not start CPR, as she was unaware of the resident's full code status at the time. The LPN was terminated for gross misconduct.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Provide and Document Bed Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to ensure that bed hold notices were provided to and signed by residents or their representatives when residents were transferred out of the facility, as required by facility policy. Clinical record reviews and staff interviews revealed that for four residents who experienced hospitalizations or transfers, there was no documentation of bed hold notifications in their medical records. Specifically, the records for these residents lacked bed hold forms for multiple hospital stays, and staff confirmed that the required notifications were not completed at the time of transfer. The residents involved had various medical conditions, including severe cognitive impairment, stroke, aphasia, hypertension, depression, acute respiratory failure, anemia, cancer, and malnutrition. In each case, the residents were transferred to the hospital for acute medical issues such as fractures, infections, or respiratory problems. Despite these transfers, the facility did not provide or document the required written bed hold notifications, as confirmed by the Director of Nursing, Assistant Director of Nursing, and Medical Records staff during interviews.
Failure to Implement Infection Prevention and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices involving several residents with complex medical needs, including those with catheters, wounds, and enteral tubes who were on Enhanced Barrier Precautions (EBP). Direct observation revealed that a registered nurse (RN) did not perform hand hygiene before donning gloves, failed to clean the blood glucose monitor between residents, and did not prime insulin pens as required. The same blood glucose monitor was used on multiple residents without proper disinfection, and the cleaning process did not adhere to the manufacturer's instructions for contact time with disinfectant wipes. The RN also admitted to not being instructed on priming insulin pens and was unaware of the required wet time for disinfectant wipes. Further observations showed that staff did not consistently use personal protective equipment (PPE) as required under EBP protocols. During wound care and catheter care for a resident, the RN failed to don PPE as mandated by EBP, despite the resident having a pressure ulcer and an indwelling catheter. In another instance, a resident with a feeding tube and an EBP sign on the door received medication and tube feeding from the RN without the use of PPE. The RN entered and exited the room multiple times, performing care activities without donning the necessary gown and gloves, even though PPE was available in the room. Interviews with the RN, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that staff were expected to follow EBP protocols, including the use of PPE during high-contact care activities for residents with wounds or indwelling devices. The DON and ADON acknowledged that the observed practices did not meet facility expectations or CDC guidelines. Facility policies reviewed by surveyors also required adherence to hand hygiene, proper cleaning of medical equipment, and the use of PPE as outlined by EBP and manufacturer instructions.
Failure to Provide Residents with Ready Access to Personal Funds
Penalty
Summary
The facility failed to provide residents with ready and reasonable access to their personal funds upon request. One resident reported that she was unable to access her personal funds during weekends and had to plan ahead to obtain money from the office before the weekend. She also stated that when she requested funds, she was told she had to wait for the office manager to be present. Staff interviews confirmed that there was no process in place for residents to access personal funds during non-business hours, and staff members were unaware of any method, such as a locked cash box, to provide funds outside of regular office hours. Further interviews revealed that the Business Office Manager acknowledged the absence of a current process for providing residents with access to their funds and noted that a lock box system had been discontinued about a year prior. The Director of Nursing was also unaware of any available personal funds on site for residents. Additionally, the facility lacked a policy related to personal funds, as confirmed by the Administrator. These actions and inactions resulted in residents not having reasonable access to their personal funds as required.
Failure to Document Non-Pharmacological Interventions and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to properly identify and document non-pharmacological interventions and targeted behaviors in the care plans for two residents who were prescribed high-risk medications. For one resident with a history of stroke, aphasia, and anxiety, the care plan did not specify targeted behaviors to monitor in relation to prescribed antipsychotic and psychotropic medications, nor did it include non-pharmacological interventions to be attempted prior to administering opioid medication for chronic pain. The Director of Nursing confirmed that these elements should have been included in the care plan. For another resident with severe cognitive impairment and a diagnosis of senile degeneration of the brain, the care plan noted the use of an antidepressant for insomnia but only included interventions to administer the medication and monitor for side effects and effectiveness. The clinical record did not contain documentation of a Gradual Dose Reduction (GDR) for the antidepressant, despite the pharmacy consultant having requested it multiple times. The facility's policy on psychotropic medications did not specifically address GDRs, and no evidence of a completed GDR was found in the resident's records.
Failure to Update Care Plan and Orders for Oxygen Therapy
Penalty
Summary
The facility failed to revise and update the care plan to include a new order for oxygen usage for one resident following a hospital discharge. Observations showed the resident was using oxygen via nasal cannula on multiple occasions, but a review of the Medication Administration Record and current physician orders did not show any documentation for oxygen usage. Additionally, the resident's care plan did not include information regarding oxygen therapy, despite the resident having a recent hospital discharge order for oxygen. Interviews with the ADON and DON confirmed that the oxygen order from the hospital discharge had been noted but was not entered into the resident's orders or care plan. The facility's policy requires the interdisciplinary team to develop and revise comprehensive care plans to reflect changes in orders or resident condition, but this was not followed in this case. The resident had diagnoses of anemia, cancer, and malnutrition, and was assessed as having no cognitive impairment.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations. This lapse resulted in the resident not receiving the individualized care and treatment that had been ordered and preferred, as documented in their care plan.
Failure to Timely Identify and Assess Significant Weight Loss
Penalty
Summary
The facility failed to promptly identify and assess a resident who experienced significant weight loss. The resident, who had severe cognitive impairment and multiple diagnoses including senile degeneration of the brain, cancer, and atrial fibrillation, was noted to have lost 6.72% of body weight in one month, dropping from 126.5 pounds to 118 pounds. The care plan in place required daily monitoring and recording of food and fluid intake, as well as regular weight checks and dietary supplements as ordered. Despite these interventions, the significant weight loss was not immediately recognized or addressed by the staff. Staff interviews revealed uncertainty about the accuracy of the resident's weight, and a reweight was not obtained promptly after the initial low measurement. The facility's nutrition policy required evaluation by the Interdisciplinary Team for any resident with a weight change of 5% in 30 days, but this process was not followed in a timely manner. Observations showed that the resident was eating with some assistance and consuming supplements, but the necessary assessment and intervention for the weight loss were delayed.
Failure to Follow Feeding Tube Medication Administration Protocol
Penalty
Summary
A deficiency occurred when a registered nurse administered enteral medications through a feeding tube to a resident who was able to take medications orally, without verifying tube placement prior to administration as required by facility policy. The nurse prepared the medications by crushing them, mixing with water, and using a syringe to push each medication swiftly through the tube, followed by water, without checking for residual or proper tube placement beforehand. During the process, the resident coughed and an orange-like substance was expelled from the tube, prompting the resident to clamp the tube. The nurse later attempted to flush the tube with water and checked lung sounds only after medication administration was completed. Additionally, medication residue was observed left in the medication cup and on the syringe, indicating incomplete administration. The resident involved had diagnoses of anemia, cancer, and malnutrition, and was cognitively intact according to the MDS assessment. Staff interviews confirmed that medications should not be pushed quickly through the tube and that tube placement must be checked prior to administration. The facility's policy required verification of tube placement before administering feedings or medications, which was not followed in this instance. The Director of Nursing acknowledged that the nurse should not have administered medications via the tube when the resident could take them orally, should not have pushed medications swiftly, and should have ensured all medication was administered without leaving residue.
Failure to Ensure Proper Communication and Documentation for Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received care and services consistent with professional standards of practice, specifically regarding communication with the dialysis center and documentation of vital signs. The resident, who had severe cognitive impairment and diagnoses including end stage renal disease and chronic obstructive pulmonary disease, was scheduled for dialysis three times a week. The care plan indicated the need for dialysis and included a fluid restriction, but the clinical record did not document the fluid restriction or any communication with the physician about it. Review of the resident's dialysis notebook revealed multiple gaps in documentation of pre- and post-dialysis vital signs over several weeks. The facility's policy required collection of dialysis run sheets and follow-up with the provider on recommendations, but these records were missing for numerous dialysis sessions. Staff interviews confirmed the absence of required documentation, and the corporate nurse was unable to locate the missing vital sign records.
Medication Error Rate Exceeds Threshold Due to Improper Insulin Administration
Penalty
Summary
A medication error rate of 6.45% was identified during a review of medication administration practices, exceeding the acceptable threshold of less than 5%. The deficiency involved two of thirty-one medications not being administered as ordered. Specifically, a resident with severe cognitive impairment and a diagnosis of type 2 diabetes mellitus had physician orders for insulin Lispro per sliding scale and insulin Glargine daily. Observation revealed that the registered nurse (RN) did not prime the insulin pens before administration, as required by facility protocol and the physician's orders. During the observed medication pass, the RN prepared and administered both insulin Lispro and insulin Glargine without priming the pens, and later confirmed in an interview that she had never been instructed to prime the insulin pen needles. The Director of Nursing (DON) stated that the facility's expectation was for 2 units to be primed after cleansing the septum and attaching the needle for each insulin pen. This failure to follow proper insulin administration technique resulted in the identified medication errors.
Significant Medication Errors Due to Improper Administration and Omission
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration practices. One resident with severe cognitive impairment and a diagnosis of type 2 diabetes mellitus was prescribed insulin Lispro via sliding scale and insulin Glargine daily. During observed administration, a registered nurse failed to prime the insulin pens before injection, a step required to ensure needle patency and accurate dosing. The nurse admitted to never having been educated on priming insulin pens, and the facility did not provide a policy or procedure for insulin pen administration. Another resident, with no cognitive impairment and a history of traumatic brain injury, aphasia, and bipolar disorder, was prescribed Levetiracetam for seizure prevention. The resident's bedtime medication was omitted by an LPN, who later acknowledged simply missing the administration. The omission was discovered the following morning when the medication was found still in the medication pack. The facility's policy required medications to be administered as ordered and within prescribed time frames, but this was not followed in this instance. Both incidents were confirmed through review of medical records, staff interviews, and direct observation. The facility's policies outlined the correct procedures for medication administration, including the seven rights of medication administration, but these were not adhered to in the cases described, resulting in significant medication errors for the two residents.
Failure to Follow Menu and Portion Sizes for Regular Diets
Penalty
Summary
The facility failed to follow the prescribed menu and provide the correct portion size of peas to residents on regular diets during a lunch meal service. Observation revealed that the Certified Dietary Manager used a 3 oz scoop to serve peas instead of the required 4 oz scoop for all regular diet residents, affecting 22 out of 26 residents reviewed. Staff acknowledged the error during the meal service, and documentation confirmed that 22 regular diets were served with the incorrect portion. The facility's policy requires adherence to planned menus and portion sizes, which was not followed in this instance.
Failure to Accurately Transcribe Physician Orders and Maintain Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not properly transcribing physician orders into the electronic health record (EHR). For one resident, the Medication Administration Record (MAR) did not match the medication bubble pack for potassium chloride. The MAR indicated a dosage of 20 mEq twice daily, while the bubble pack and hospital discharge instructions specified 40 mEq daily. Staff interviews confirmed the discrepancy, and the Director of Nursing acknowledged the MAR was incorrect. Facility policy required that verbal orders be recorded immediately and accurately in the resident's chart, but this was not followed in this instance. For another resident, observations showed the individual was using oxygen, but there were no corresponding orders for oxygen use in the MAR, Treatment Administration Record (TAR), or current physician orders. The care plan also lacked information about oxygen usage. Staff interviews revealed that the oxygen order was present in the hospital discharge paperwork but was not transcribed into the facility's records upon the resident's return. The facility did not provide a policy for maintaining accurate resident records in this case.
Failure to Document Pneumococcal Vaccine Offer and Education
Penalty
Summary
The facility failed to properly screen, offer, provide education, and document consent or refusal for the pneumococcal immunization for one resident. Clinical record review showed that the resident, who was cognitively intact, had previously received PCV13 and PPSV23 vaccines, but there was no documentation that the resident was educated about, offered, or provided the opportunity to consent to or refuse the recommended PCV20 or PVC21 vaccination, as per updated CDC guidelines. Staff interviews confirmed that the expectation was for vaccinations to be offered according to resident preference, with education provided if refused. The facility's own policy required offering the pneumococcal immunization unless contraindicated or already administered, and mandated education about benefits and side effects prior to offering the vaccine. However, these steps were not documented for the resident in question.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in their care. Resident #50, who had a diagnosis of essential hypertension and localized edema, was prescribed diuretics but did not have a care plan that included focus, goals, or interventions related to the use of these medications. The MDS Coordinator and the Director of Nursing acknowledged the absence of necessary interventions such as lab work, monitoring blood pressure, and notifying the doctor of adverse reactions. Resident #20, who was transferred to the hospital for a low oxygen saturation and later admitted for congestive heart failure (CHF) exacerbation, did not have a care plan that included CHF focus or diagnosis-related interventions. Although a baseline care plan was created, it was not updated to reflect the resident's current condition after the hospital admission. This oversight was noted during the review of the resident's records. Resident #43, who was receiving hospice care, had a care plan that failed to document the terminal prognosis, the hospice company providing services, or contact information. The MDS Coordinator stated that hospice information was kept in a separate notebook, not included in the facility's comprehensive care plan. Additionally, Resident #3, who required assistance with eating, was observed eating unsupervised on multiple occasions, contrary to the care plan's directive for staff assistance. The facility's policy on comprehensive person-centered care planning was not adhered to, as evidenced by these deficiencies.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Observations and interviews revealed that call lights were not answered promptly for five residents, with delays ranging from 15 minutes to over an hour. Resident #1, with no cognitive impairment, waited 27 minutes for assistance to use the toilet. Resident #17, with moderate cognitive impairment, experienced a 22-minute delay for help transferring to bed. Resident #37, with no cognitive impairment, reported frequent delays exceeding 15 minutes, while Resident #6, with intact cognition, mentioned waiting up to 45 minutes and being left in the dining room for extended periods. Resident #106, also with intact cognition, reported delays over an hour, with staff sometimes turning off the call light without addressing her needs. The facility's policy requires call lights to be answered within a reasonable time, with the expectation set by the Administrator and Director of Nursing (DON) at 15 minutes, though the DON preferred a 5-minute response time. Staff B, a CNA, was observed responding to call lights but was unsure of the facility's expectations for response times. The facility's failure to adhere to its policy and expectations resulted in significant delays in addressing residents' needs, as evidenced by the experiences of the five residents reviewed.
Failure to Post Daily Census Sheet
Penalty
Summary
The facility failed to post the daily census sheet, which includes the resident census and the actual working hours of nurses and nurse aides on duty for the current date. On the morning of 8/21/24, it was observed that there was no visible census posting in the Longhouse portion of the facility. A Licensed Practical Nurse (LPN) stated that the census sheet for the day had not been completed yet and that the prior day's posting was likely in the medication room. Upon retrieving the keys to the medication room, the LPN found census sheets dated from 8/16/24 to 8/19/24, but was unsure if a sheet for 8/20/24 had been completed, as she was off work that day. A census for 8/21/24 was subsequently filled out and displayed in the dining room. The Administrator later confirmed that the daily census posting should be initiated by the charge nurse for each shift, starting with the day shift at 6:00 am, and that the previous day's census should not be removed until the new one is posted.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary practices in food handling and storage, as observed during a survey. On two separate occasions, black and pink substances were found on the internal plastic ice cube guard edges in both the north and south building kitchens. Additionally, a Dietary Aide was observed transporting a gallon of milk without a lid, and the Dietary Manager improperly handled salt and pepper packets by placing them directly on a resident's plate after use. Further observations revealed improper glove use and hand hygiene practices by staff members. A cook was seen adjusting gloves and touching non-food preparation surfaces before handling food without changing gloves or performing hand hygiene. Another Dietary Aide handled bread with the same gloves used to open the packaging, again without changing gloves or washing hands. These actions were contrary to the facility's Food Safety and Sanitation policy, which requires staff to handle food safely and wash hands after unsanitary contact.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by several observations and staff interviews. Staff were observed transporting clean linen carts uncovered between buildings and in hallways, contrary to the facility's policy that requires linen to be covered during transport. Additionally, staff did not follow proper hand hygiene protocols, as they failed to wash hands between resident contacts and after handling contaminated items. This was observed during medication administration and feeding of residents, where staff did not perform hand hygiene between tasks or after touching potentially contaminated surfaces. In one instance, a staff member did not properly disinfect a wheelchair after it was contaminated during personal care for a resident with transmission-based precautions. The staff member acknowledged not allowing the sanitizing wipes to remain moist on the surface for the required two minutes, as per the instructions. This resident, who had an indwelling catheter and diagnoses of bullous pemphigoid and herpes viral infection, required enhanced barrier precautions, which were not adequately followed. The Director of Nursing confirmed the facility's expectations for infection control practices, including covering linen carts, performing hand hygiene, and using sanitizing wipes correctly. However, these expectations were not met, as evidenced by the observations and staff admissions. The facility's policies on hand washing and the use of sanitizing wipes were not adhered to, leading to deficiencies in infection prevention and control practices.
Deficiencies in Resident Accommodation and Maintenance Reporting
Penalty
Summary
The facility failed to provide a call light system within reach for a resident under contact precautions, and did not accommodate the needs of another resident with a malfunctioning closet door. Resident #22, who had moderate cognitive impairment and was under transmission-based precautions due to a severe acute respiratory infection related to a COVID diagnosis, was observed without a call light within reach. The call light was found on a recliner on the opposite side of the room, and both the Certified Nursing Assistant and the Director of Nursing acknowledged that the call light should have been within reach while the resident was in bed. The facility's policy required that residents have a means of communication with nursing staff, which was not adhered to in this instance. Resident #9, who had severely impaired cognition and required assistance with dressing, was found to have a closet door that was not attached to the overhead track, making it difficult to open. Additionally, a toilet safety rail was observed on the shower floor. Despite these issues being observed over multiple days, the Maintenance Supervisor was not aware of them and did not have a consistent process for identifying and addressing maintenance needs. The facility's maintenance policy required staff to report issues in a log book, but the Maintenance Supervisor did not maintain a separate log of needed repairs and had not transitioned to a new computer system for tracking maintenance requests.
Failure to Include Psychotropic Medication in Baseline Care Plan
Penalty
Summary
The facility failed to include psychotropic medications in the baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, who had intact cognition with a BIMS score of 15 out of 15, was diagnosed with diabetes mellitus, cerebrovascular accident, depression, and metabolic encephalopathy. The resident was taking an antidepressant, duloxetine, as directed by the hospital discharge medication list. However, the baseline care plan did not reflect the use of this psychotropic medication until 10 days after admission. The MDS Coordinator confirmed the omission, and the Director of Nursing acknowledged that medications should be reviewed and included in the baseline care plan promptly.
Failure to Update Care Plan After Medication Change
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident diagnosed with non-Alzheimer's dementia and depression. The resident's Minimum Data Set (MDS) dated June 7, 2024, documented the use of antidepressant medications, including mirtazapine and sertraline. However, the medication history showed that the order for mirtazapine was discontinued on June 11, 2024. Despite this change, the care plan was not updated to reflect the discontinuation of mirtazapine. The MDS Coordinator acknowledged that care plans should be updated with medication changes and that a medication change from June should have been reflected in the care plan. The care plan review for the resident was last completed on February 2, 2024, and the next review was scheduled for May 2, 2024, but was not conducted. The facility's policy on comprehensive person-centered care planning, revised in March 2022, requires the interdisciplinary team to review and revise the resident's comprehensive plan of care after each assessment. The failure to update the care plan following the discontinuation of mirtazapine indicates a lapse in adhering to the facility's policy and ensuring accurate and current care plans for residents.
Failure to Follow Physician Orders for Resident Weight Monitoring
Penalty
Summary
The facility failed to follow physician orders regarding the monitoring of a resident's weight upon admission. Resident #106, who was admitted to the facility with intact cognition, had a physician's order to have their weight taken upon admission, daily for three days, and then weekly for four weeks. However, discrepancies were found between the Medication Administration Record (MAR) and the Electronic Health Record (EHR). The MAR indicated weights were recorded on specific dates, but the EHR only showed weights on two different dates, suggesting a failure to accurately document the resident's weight as ordered. Interviews with staff and the resident further highlighted the inconsistency in weight documentation. Staff A, an LPN, claimed to have entered the weights in the EHR before signing the MAR, yet the weights were not present in the EHR. The resident also reported being weighed only once since admission, contradicting the MAR entries. The facility's policy requires accurate implementation of physician orders, including documentation in the Weight Summary section of the resident's chart, which was not adhered to in this case.
Failure to Provide Restorative Exercise Program
Penalty
Summary
The facility failed to provide a Restorative Exercise Program for a resident with severe cognitive impairment and functional limitations in range of motion affecting all four limbs. The resident was totally dependent on staff for daily activities and had contractures in both arms. The initial care plan included a directive for a Restorative Exercise Program for Functional Maintenance, but the current care plan did not include any such program. The facility had previously discontinued all restorative programs following a deficiency noted in a prior survey. The MDS Coordinator confirmed that residents were being reassessed for restorative programs, but no restorative staff were employed at the time. The facility's administrator stated that there was no policy on Restorative Exercise, and the staff had been directed to discontinue all restorative programs after a change in ownership. Certified Nurse Aides were expected to perform restorative programs, but no range of motion programs were in place for any residents.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) for two residents, which is a requirement under federal regulations for the use of psychotropic medications. Resident #19, diagnosed with non-Alzheimer's dementia and depression, had their antidepressant medication, Sertraline, reduced from 25 mg to 12.5 mg over a year ago. Despite the absence of depressive symptoms since the reduction, there was no documentation of attempts to discontinue the medication entirely to assess if the resident could maintain symptom-free without it. Similarly, Resident #14, who has severe cognitive impairment, was prescribed mirtazapine and escitalopram for recurrent depressive disorders. The facility was unable to provide documentation of GDR recommendations or physician follow-up for these medications over the past 13 months. The Director of Nursing (DON) acknowledged the difficulty in locating GDR records due to a transition from paper to electronic files and a change in facility ownership, which affected the organization of documents. The facility's policy requires GDRs and behavioral interventions unless clinically contraindicated, but these were not completed as expected.
Failure to Serve Correct Therapeutic Diet
Penalty
Summary
The facility failed to serve the correct therapeutic diet to a resident who was ordered a renal diet. The resident, who had intact cognition and diagnoses including anemia, coronary artery disease, heart failure, hypertension, renal disease, and diabetes mellitus, was observed receiving regular diet menu items instead of the prescribed renal diet. The electronic health record showed a physician order for a renal diet dated 10/05/22. During a lunch meal service, the cook served the resident regular diet items, including carrots, which were not on the menu for that day. The dietary manager confirmed that all diets should have included green beans, as indicated on the week 5 menu for modified renal diets. A dietary aide later stated that frozen carrots were used as a substitution due to the unavailability of frozen green beans. The facility's policy directed staff to ensure the correct tray is served to the right resident, which was not followed in this instance.
Failure to Implement CPR for Full Code Resident
Penalty
Summary
The facility staff failed to implement CPR for a resident who was found unresponsive with no pulse or respirations, despite the resident's documented request for CPR. The resident had a history of a fracture of the left wrist and hip and was admitted to the facility from the hospital. The resident's care plan and electronic health record indicated that she was a full code, meaning she desired CPR in the event of cardiopulmonary or respiratory arrest. On the day of the incident, a CNA found the resident unresponsive and summoned an LPN, who verified the absence of vital signs but did not initiate CPR. The LPN did not check the resident's code status and left the room without performing resuscitation efforts. Another RN later confirmed the absence of vital signs but also did not initiate CPR, as she was unaware of the resident's full code status at the time. Interviews with the staff revealed that the CNA noticed the resident's fixed gaze and lack of response, prompting her to call the LPN. The LPN observed the resident's condition, noted the absence of vital signs, and heard the resident take several sharp breaths but did not start CPR. The RN, who was called to confirm the absence of vital signs, found the CNA performing post-mortem care and did not question the LPN about the resident's code status. The Director of Nursing (DON) later confirmed that the resident had a current and active order for CPR and that the LPN had failed to adhere to the facility's CPR policy. The facility's policy required staff to administer CPR according to current national guidelines and to continue CPR until the arrival of rescue personnel or a physician's order to discontinue. The LPN involved was terminated for gross misconduct and failure to perform CPR on a resident with a full code status. The facility identified a total of 13 residents who had requested CPR at the time of cardiopulmonary or respiratory arrest.
Removal Plan
- All staff educated on the importance of CPR policy and protocol and what to do in the event of a non-responsive resident.
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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