Stacyville Community Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Stacyville, Iowa.
- Location
- 413 South Broad Street, Stacyville, Iowa 50476
- CMS Provider Number
- 165438
- Inspections on file
- 19
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Stacyville Community Nursing Home during CMS and state inspections, most recent first.
A resident with intact cognition and multiple diagnoses, including Parkinson’s disease and depression, was receiving lorazepam when an LPN failed to sign out a controlled dose at the time of administration, later assumed it had not been given, and administered a second dose, resulting in a double dose and a missing, unaccounted-for dose. Video footage showed an RN removing the resident’s lorazepam and taping it into another resident’s controlled drug card during a controlled drug count. The resident’s EHR lacked documentation of the medication error, and the controlled drug count sheet for the period was missing. Surveyors also observed two CMAs and an LPN conducting shift-change controlled drug counts without comparing bubble packs to the count sheets to verify the correct resident, medication, and count, despite policies requiring proper reconciliation and documentation of controlled substances and medication errors.
A resident with intact cognition and multiple diagnoses, including Parkinson's disease and depression, was prescribed lorazepam. An LPN failed to sign out a controlled dose when first administered, later assumed the dose had not been given, and administered a second dose, resulting in a double dose of lorazepam. The medication error, including assessment and follow-up, was not documented in the EHR, despite facility policy requiring documentation of medication errors and monitoring for adverse effects.
A resident with intact cognition and multiple medical conditions reported missing money on two occasions, informing staff each time. Although staff initiated an internal investigation, the facility did not report the allegations of misappropriation to the state authorities as required by policy and regulation.
A resident who elected to begin hospice care did not have a Significant Change Status Assessment (SCSA) MDS completed as required. Staff and administration confirmed that the assessment was not performed within the mandated 14-day period following the initiation of hospice services, despite facility awareness of the regulatory requirement.
A resident's MDS assessment was inaccurately completed, showing daily insulin injections during the lookback period despite no documentation of such administration in the clinical record. The error was attributed to incorrect coding by a previous MDS coordinator, and the facility lacked a specific policy for MDS accuracy, relying solely on the RAI Manual.
Two residents did not receive services as ordered by their physicians: one did not receive a prescribed GLP1 medication due to a missed pharmacy delivery, and another did not receive ordered PT because staff failed to notify the therapy group. Staff interviews confirmed both omissions and the absence of a facility policy for following physician orders.
The facility did not have an effective QAPI program in place, as evidenced by repeated deficiencies in Resident Rights, Pharmacy Services, and QAPI. The Business Office Manager attributed the ongoing ineffectiveness to challenges from previous management and the current management team's learning curve.
Staff removed an electric wheelchair from a resident with intact cognition and physician orders for its use, without obtaining a discontinuation order. The resident, who relied on the wheelchair for mobility due to Parkinson's disease and a history of falls, experienced a significant loss of independence and had to wait for staff assistance as a result.
The facility did not ensure that care plans were complete and individualized for four residents, omitting prescribed restorative nursing programs and failing to update plans after significant changes in mobility or fall risk. For example, a resident with Parkinson's disease continued to have incidents with an electric wheelchair without care plan revision, and two residents with restorative therapy orders did not have these interventions reflected in their care plans.
Several residents with limited ROM and mobility needs did not consistently receive prescribed restorative nursing programs, as care plans failed to address these needs and documentation showed restorative services were only provided sporadically. Staff interviews confirmed that restorative care was often missed due to staffing shortages, resulting in a failure to maintain or improve residents' functional abilities.
A resident received compounded topical medications when an LPN mixed Nystatin powder and Clotrimazole Betamethasone cream without a physician order, using estimated amounts. This practice was identified as outside professional standards and not within the nursing scope of practice, as confirmed by facility administration.
An LPN was found sleeping in the front lounge while on duty, as confirmed by a photo and interviews with two residents and a CNA. The LPN, who worked from afternoon to early evening, did not take a scheduled break. The facility's administrator stated that sleeping in the lounge is unacceptable.
The facility failed to ensure competent care for residents, as an LPN administered IV medications without proper certification, diagnosed a resident without authority, and used Snapchat for communication with hospital staff. Additionally, staff lacked training to manage erratic behaviors, highlighting deficiencies in staff competencies and communication protocols.
The facility failed to provide an RN for eight consecutive hours per day and did not designate a qualified RN as the DON. An LPN was improperly promoted to Interim DON and directed to perform tasks beyond her scope without proper training. The facility's administrative staff confirmed the lack of adequate RN staffing.
The facility failed to provide effective leadership by appointing an LPN as Interim DON without the required RN qualification, leading to inadequate training and improper medication administration. An RN felt uncomfortable administering morphine to a resident due to family objections and reported feeling degraded by the Interim DON. The facility also lacked a proper chain of command for addressing concerns.
The facility failed to maintain an effective QA program, resulting in insufficient RN coverage for 10 days out of 90. Despite having 51 staff members and efforts to recruit more, the facility's documentation lacked plans to address the nursing staff issue, contributing to inadequate RN coverage.
A resident with intact cognition reported an unpleasant interaction with an LPN, who responded dismissively when asked about dining area management. The LPN's tone upset the resident, and a CNA witnessed the LPN rolling her eyes at another resident requesting pain medication. These actions violated the facility's Residents' Rights, which require treating residents with respect and dignity.
A facility staff failed to follow professional standards when a RN drew up liquid morphine without a witness, and an LPN administered it to a resident without verifying the contents. This incident violated the facility's policy on controlled substances, which requires reconciliation at various stages. The resident involved had been assessed to receive opioid medication.
A facility failed to maintain suction equipment, leading to critical incidents involving two residents. One resident choked on peanut butter crackers, and the suction machine failed to operate, necessitating manual intervention. Another resident was unable to clear aspirations due to a malfunctioning suction machine with the wrong canister. These incidents highlight the facility's failure to ensure essential equipment was in safe operating condition.
The facility failed to report missing narcotics from the emergency narcotic lock box within the required 24-hour timeframe. A discrepancy was identified, but the facility did not report the missing narcotics to the Department until several days later. The Interim Administrator and the current Administrator acknowledged the delay, attributing it to their ongoing investigation process.
A resident with moderately impaired cognition experienced severe abdominal pain, but the facility failed to conduct a comprehensive assessment or document necessary interventions. Despite the resident's distress and elevated blood pressure, the initial evaluation lacked vital checks like bowel and lung sounds. This oversight did not align with the facility's policy for managing changes in a resident's condition.
A facility failed to ensure a safe environment when a nurse found a marijuana pipe and a Lasix bottle with unknown contents in a resident's drawer. The resident, with intact cognition, was told the items could be locked up or picked up by his daughter. The nurse did not confiscate the items and lacked the daughter's contact information. The clinical record did not document a physician's order for marijuana use or follow-up on the items.
A resident with intact cognition received another resident's medications due to a nurse's error in identity verification, leading to sedation and hospitalization. The nurse, unfamiliar with the residents, administered medications based on last names, not realizing the presence of two residents with similar names. The resident exhibited signs of sedation and was difficult to wake, prompting eventual hospitalization for further evaluation.
The facility did not have an RN on duty for eight consecutive hours on multiple occasions, as required by Federal Regulations. This deficiency was identified through a review of timesheets and schedules, and the Administrator acknowledged a misunderstanding regarding a waiver for RN coverage.
A facility failed to update a resident's PASRR to include new diagnoses of major depression disorder and unspecified psychosis. The resident's MDS assessment reflected these conditions, but the PASRR, dated over four years prior, did not. The oversight was identified during a survey, prompting the Administrator to submit the PASRR for review, which triggered a Level II review. The facility's policy lacked guidance on submitting new mental health diagnoses for PASRR review.
The facility failed to complete comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. One resident's care plan did not include the use of bed rails, another's inaccurately addressed bladder incontinence instead of a urinary catheter, and a third resident's care plan lacked specific interventions, despite expectations for completion within 21 days of admission.
A facility failed to update a resident's care plan to include interventions for major depression disorder and unspecified psychosis, despite these diagnoses being documented in the resident's medical record. The care plan lacked necessary instructions and interventions, as identified during a record review and staff interview.
A resident with intact cognition expressed a desire to transfer to another facility, feeling like a prisoner. Despite her request, the care plan lacked interventions for her discharge, and the facility's policy did not guide staff on incorporating residents' wishes into discharge planning. The DON noted the resident required 24-hour care.
The facility did not have a qualified Infection Preventionist to oversee its infection prevention program. An RN, referred to as Staff A, had completed the required class but had not taken the certification test. The facility had 31 residents at the time.
A facility failed to ensure a resident received Olanzapine only for psychiatric or mood disorders upon admission. The resident, with intact cognition, was prescribed Olanzapine for dementia without disturbances, despite no prior use before hospitalization. The care plan lacked a comprehensive review for antipsychotic use, and the DON was unaware of the medication's use for dementia.
The facility failed to properly sanitize blood sugar meters and use barriers during blood sugar checks and insulin administration for three residents with diabetes. Staff did not clean the meters between uses, contrary to guidelines and manufacturer instructions, leading to deficiencies in infection control practices.
The facility failed to document education and consent for flu vaccinations for three residents. One resident received their last flu vaccine years ago, another never received it, and the third had no recent record. The Infection Preventionist did not document education on vaccine risks and benefits or the residents' decisions to accept or decline the vaccine, as required by the facility's program.
The facility inaccurately reported its Payroll Based Journal (PBJ) for licensed nursing staff, indicating a lack of 24/7 coverage, despite timecards showing continuous coverage. The Administrator acknowledged the error in submission, affecting a facility with 31 residents.
The facility inaccurately documented MDS assessments for four residents, including incorrect coding of bed rails as restraints and failure to document opioid and anticoagulant medication administration. The DON and Administrator acknowledged these errors.
Failure to Prevent, Document, and Reconcile Controlled Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to prevent a medication error for one resident, to document that error in the clinical record, and to follow professional standards for reconciling controlled substances. A resident with intact cognition and diagnoses including Parkinson’s disease, depression, and sleep apnea was receiving lorazepam, an antianxiety medication. On one occasion, an LPN did not sign out the controlled medication at the time of administration, later believed the dose had not been given, and administered another dose around 8:00 PM. When the LPN subsequently signed the controlled drug record, she realized a double dose had been given. The facility’s investigation also identified that another dose of lorazepam for this resident was missing and unaccounted for, and video footage showed an RN punching out the resident’s lorazepam and taping it into another resident’s controlled drug card during the controlled drug count. The resident’s EHR contained no documentation of the medication error, and the controlled drug count sheet for the relevant period was missing. Surveyors also observed ongoing failures in the controlled substance reconciliation process. During a shift-change controlled drug count, two CMAs conducted the count by having one staff member look at the bubble packs while the other read the counts from the controlled drug sheets, without comparing the bubble packs to the sheets to verify the correct resident, medication, and count. An LPN stood by observing this process, and all three staff confirmed this was their normal method for counting controlled drugs. The DON later confirmed that staff had completed the count incorrectly and that the facility’s policies required reconciliation of controlled substances upon receipt, administration, disposal, and at the end of each shift, as well as documentation of medication errors in the resident record and completion of a medication error form. Despite these policies, the medication error for the resident and the associated controlled drug discrepancies were not properly documented or reconciled.
Failure to Prevent and Document Significant Medication Error
Penalty
Summary
The facility failed to ensure a resident remained free from a significant medication error and failed to document the error and related assessment in the clinical record. The resident had intact cognition with a BIMS score of 15 and diagnoses including Parkinson's disease, depression, and sleep apnea, and was receiving an antianxiety medication. An incident investigation for missing controlled drugs documented that a nurse did not sign the controlled drug record at the time of administration, which led to a double dose of lorazepam being given to this resident. The nurse later returned to sign out the medication, believed the resident had not yet received it, and administered another dose around 8:00 PM before realizing the error when signing the controlled drug record. The resident's EHR contained no documentation of the medication error, no assessment, and no follow-up related to the incident. The DON confirmed that there was no information in the EHR documenting the medication error, assessment, or follow-up, despite the facility’s Medication Error-Incident Report Process policy directing that a medication error must be documented in the resident record and that residents must be monitored for any adverse effects caused by the error. The failure to document and assess the resident following the double administration of lorazepam constituted the deficiency identified by surveyors.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's property within the required timeframe to the Iowa Department of Inspection, Appeals, and Licensing (DIAL). A resident with intact cognition and a history of renal insufficiency, stroke, and end stage renal disease reported missing money on two separate occasions, totaling over $300. The resident stated he informed staff each time money was missing from his room. Staff interviews confirmed that the missing money was reported internally to nursing and administrative staff, and an investigation was initiated by the facility. Despite the facility's policy requiring immediate reporting of all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation to the appropriate authorities, there was no evidence that the incidents involving the resident's missing money were reported to DIAL as required. The administrator acknowledged that neither the previous nor the current incidents of missing money were reported to DIAL, in violation of both facility policy and regulatory requirements.
Failure to Complete SCSA MDS Assessment After Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change Status Assessment (SCSA) Minimum Data Set (MDS) assessment for a resident who elected to begin hospice care. According to the clinical census and health status notes, the resident's primary payer changed to hospice, and hospice services were initiated. The resident's representative signed a hospice election statement, confirming the start of hospice care. However, review of the MDS 3.0 Summary page in the electronic health record revealed that the required SCSA MDS assessment was not completed following the election of hospice services. Interviews with the MDS Coordinator and the Administrator confirmed that the facility was aware of the requirement to complete the SCSA within 14 days of the significant change, as outlined in the RAI manual. Both staff members acknowledged that the assessment was not completed for the resident after the initiation of hospice care. The RAI manual specifically requires an SCSA when a terminally ill resident enrolls in hospice while remaining in the facility, with a completion deadline of 14 days from the determination of the significant change.
Inaccurate MDS Assessment Due to Incorrect Medication Coding
Penalty
Summary
The facility failed to accurately document and submit a correct Minimum Data Set (MDS) assessment for one resident. The MDS assessment for this resident indicated a Brief Interview of Mental Status (BIMS) score of 13, reflecting intact cognition, and listed diagnoses of hypertension, diabetes, and obesity. The assessment also reported that the resident received insulin injections daily during the lookback period. However, a review of the clinical record revealed no documentation of insulin administration or any injections during that period. Interviews with the MDS coordinator confirmed that the previous coordinator had incorrectly coded the medication administration, and it was also noted that the facility did not have a policy in place for ensuring MDS accuracy and completion, relying instead on the RAI Manual.
Failure to Follow Physician Orders for Medication and Therapy
Penalty
Summary
The facility failed to follow physician's orders for two residents. For one resident with diagnoses of hypertension, diabetes, and obesity, the Treatment Administration Record did not show documentation that Ozempic, a GLP1 medication, was administered as ordered on 4/4/25. Progress notes indicated the medication was expected from the pharmacy that evening, but there was no further documentation confirming its receipt or administration. Staff interviews confirmed the medication was missed because it did not arrive from the pharmacy, and the facility lacked a policy related to following physician orders. For another resident with diagnoses of hypertension, depression, and dementia, a physician ordered physical therapy (PT) evaluation and treatment after the resident expressed a desire to use the therapy bike. However, the clinical record did not show that PT was provided following the order. Staff interviews revealed that nursing staff are responsible for notifying the contracted therapy group of new orders, but the order for PT was missed and not communicated, resulting in the therapy not being initiated.
Ineffective QAPI Program and Ongoing Deficiencies
Penalty
Summary
The facility failed to maintain an effective quality assurance (QA) program to support the provision of quality care for its residents. A review of facility records and staff interviews revealed that the facility received deficiencies in Resident Rights, Pharmacy Services, and Quality Assurance and Performance Improvement (QAPI) during a complaint survey. The survey investigation found that these deficient practices persisted during a subsequent complaint and revisit investigation. The Business Office Manager, who was responsible for monitoring the QAPI program, stated that the program remained ineffective due to issues with previous management and the ongoing learning curve of the current management staff.
Failure to Honor Resident's Right to Self-Determination in Wheelchair Use
Penalty
Summary
Facility staff failed to honor a resident's right to self-determination and to follow physician orders regarding the use of an electric wheelchair. The resident, who had intact cognition as indicated by a BIMS score of 13 and diagnoses including Parkinson's disease, anxiety, and repeated falls, was care planned and had a physician's order to use an electric wheelchair at the lowest speed with close staff supervision. Despite these orders and interventions, staff removed the resident's electric wheelchair without first obtaining a physician's order to discontinue its use. As a result, the resident reported a significant negative impact on his mobility and independence, stating that he could no longer get around and had to wait for staff assistance, which he disliked. The resident acknowledged occasionally hitting walls but denied causing injury to himself or others. The facility's Residents' Rights form affirms the right to reasonable accommodation unless it endangers health or safety, but there was no documentation that the resident's use of the wheelchair posed such a risk at the time it was taken away.
Failure to Maintain Complete and Accurate Care Plans for Multiple Residents
Penalty
Summary
The facility failed to maintain complete and accurate care plans tailored to the individual needs of four residents. For two residents with documented functional limitations and restorative nursing recommendations, their care plans did not address the prescribed restorative programs, despite clinical records indicating scheduled exercise, range of motion (ROM), and ambulation interventions. These omissions were confirmed by both clinical documentation and facility administration. Another resident, who had a history of Parkinson's disease, anxiety, and repeated falls, experienced multiple incidents involving unsafe operation of an electric wheelchair. Despite documented staff observations, family communication, and a physician's directive to restrict wheelchair speed and provide close supervision, the care plan was not revised after the resident's electric wheelchair was removed. The resident reported significant changes in mobility and independence following this removal, but the care plan did not reflect these changes or new interventions. A fourth resident with upper extremity ROM limitations and a moderate fall risk, as indicated by assessment tools and restorative nursing recommendations, also had a care plan that failed to address both her restorative program and her risk for falls. The facility's own review confirmed these omissions in the care plans for two residents, and documentation showed that the care plans did not reflect the residents' current needs or prescribed interventions.
Failure to Provide Consistent Restorative Services for Residents with Limited ROM
Penalty
Summary
The facility failed to provide restorative services to residents with limited range of motion (ROM) and mobility needs, as evidenced by gaps in the delivery and documentation of restorative nursing programs for three residents. For one resident with functional limitations in both lower extremities and dependent on a wheelchair, the care plan did not address her prescribed restorative program, and flow records showed restorative exercises were only documented on a few days each month, with no indication of services being offered or provided on other days. Another resident, who used a walker and wheelchair and had intact cognition, also had a prescribed restorative program that was not reflected in the care plan, and documentation showed restorative services were provided infrequently, with large gaps in the records. This resident reported that restorative exercises were only performed when staff availability allowed. A third resident with upper extremity ROM limitations and moderate fall risk was similarly affected. Her care plan did not address her restorative program, and flow records indicated restorative services were documented on only a few days each month, with no evidence of services being offered or provided on other days. Staff interviews confirmed that restorative programs were inconsistently implemented, often depending on CNA availability and staffing levels. Staff acknowledged that restorative care was not always completed due to staffing issues, and the ADON could not confirm whether restorative tasks were performed as assigned when CNAs were reassigned to other duties. The lack of consistent restorative care and documentation for these residents, despite identified needs and prescribed programs, demonstrates a failure by the facility to maintain or improve residents' highest level of functioning. The deficiency was identified through observation, clinical record review, and staff interviews, with a total facility census of 27 residents at the time of the survey.
Improper Compounding of Topical Medications by Nursing Staff
Penalty
Summary
Facility staff failed to follow professional standards of practice by allowing a Licensed Practical Nurse (LPN) to compound, or mix together, treatment ointments and creams prior to application for a resident. Specifically, the LPN mixed Nystatin powder and Clotrimazole Betamethasone cream on two separate occasions, basing the amounts on estimation rather than precise measurement. The resident's clinical record did not contain a physician order authorizing the compounding of these treatments. Another LPN identified this practice as unacceptable and redirected the staff member involved. The facility administrator confirmed that compounding these medications was not in accordance with acceptable practice and was outside the scope of practice for nursing staff.
LPN Found Sleeping on Duty
Penalty
Summary
The facility failed to ensure that a licensed nurse was awake and capable of rendering nursing services during a shift, as required. On the evening of January 22, 2024, Staff C, an LPN, was observed sleeping in the front lounge of the facility. This was confirmed by multiple sources, including a photograph showing Staff C reclined in a chair with her eyes closed, and interviews with residents and staff. Resident #12, with intact cognition, reported seeing Staff C asleep, while Resident #9, also with intact cognition, attempted to speak with Staff C during this time. Staff C was later escorted out of the building by another staff member. The incident was further corroborated by a written statement from Staff E, a CNA, who witnessed Staff C sleeping while on duty. A review of Staff C's time card indicated she worked from 1:52 PM to 6:29 PM on the day in question. An email from the Administrator noted that Staff C did not take a scheduled break and emphasized that sleeping or meditating in the lounge area is unacceptable. The facility reported a census of 28 residents at the time of the incident.
Incompetent Staff and Inappropriate Communication Methods
Penalty
Summary
The facility failed to ensure that its nursing staff had the appropriate competencies to care for residents, as evidenced by several deficiencies. An LPN administered intravenous medications via a peripherally-inserted central catheter (PICC) to a resident without having the necessary Iowa-approved certification. This resident, who had a history of wound infection and pulmonary embolism, received antibiotics through a central line, but the LPN's certification from the Mayo Clinic was not recognized by the Iowa Board of Nursing. The facility's failure to ensure that the LPN had the proper certification for IV therapy in Iowa led to this deficiency. Additionally, the facility's staff demonstrated a lack of understanding of their professional scope of practice. An LPN diagnosed a resident with a transient ischemic attack (TIA) without being present in the facility or having the authority to make such a diagnosis, which is outside the scope of practice for nurses. This action was based on a previous physician's statement and was confirmed through a video recording. Furthermore, the facility staff used an unsecured social media platform, Snapchat, to communicate with hospital staff about residents' conditions, which is inappropriate and breaches confidentiality protocols. The facility also failed to provide adequate training for managing residents with erratic behaviors or suspected drug use. An LPN reported that the facility management did not educate her on handling such situations, indicating a gap in staff training and preparedness. This lack of training and inappropriate communication methods contributed to the overall deficiency in ensuring competent care for residents.
Failure to Provide RN Coverage and Designate Qualified DON
Penalty
Summary
The facility failed to comply with federal regulations by not providing a Registered Nurse (RN) for eight consecutive hours per day. This deficiency was identified through a review of staffing calendars, time cards, and staff interviews, which revealed multiple dates where the facility did not meet the required RN coverage. The facility's administrative staff confirmed the lack of adequate RN staffing in an email communication. Additionally, the facility did not designate a RN as the Director of Nursing (DON), which is another requirement under federal regulations. The facility employed an LPN, referred to as Staff B, as an Interim DON, which is outside the scope of practice for an LPN. Staff B was initially hired as a part-time charge nurse and later promoted to the Interim DON position. During her tenure, she was directed by the Provisional Administrator and the Board of Directors to perform tasks beyond her scope, such as flushing PICC lines, without proper training. Staff B was eventually terminated for failing to adhere to nursing standards of practice.
Leadership and Training Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide effective leadership by not adhering to Federal Regulations and state rules, specifically by not having a Registered Nurse (RN) designated as the Director of Nursing (DON). Instead, the provisional Administrator appointed a Licensed Practical Nurse (LPN) as the Interim DON, despite knowing she did not possess the required RN qualification. This decision was made without ensuring a proper chain of command for addressing concerns related to the DON. The facility, which had a census of 28 residents, also failed to provide adequate training for the Interim DON, as evidenced by an email where she reported receiving only 2.5 shifts of training from an actual nurse. In one incident, a Registered Nurse (RN) drew up a dose of liquid Morphine for a resident without a witness and took it to the Administrator's office. After a dispute, the Interim DON administered the medication to the resident without direct knowledge of the syringe contents. The RN felt uncomfortable with the situation, especially since the resident's family continuously denied the administration of morphine. Additionally, the RN reported feeling degraded by the Interim DON, which affected her confidence. An audio recording revealed a discussion where the RN was advised to show confidence in front of families and to report non-clinical concerns about the Interim DON to the Administrator.
Deficiency in RN Coverage Due to Ineffective QA Program
Penalty
Summary
The facility failed to maintain an effective quality assurance program, which resulted in insufficient nursing staff coverage. Specifically, the facility did not schedule a Registered Nurse (RN) for at least 8 consecutive hours a day for 10 days out of a 90-day period. This deficiency was identified during a Recertification, Complaint, and Incident survey. The facility had a census of 28 residents at the time of the survey. The facility's Quality Assurance Performance Improvement (QAPI) meeting minutes and Quality Improvement Plan of Action forms lacked documentation and plans addressing the nursing staff issue. Despite having 51 staff members and efforts to recruit more, the facility's documentation did not reflect any progress or plans related to resolving the nursing staff deficiency. This lack of documentation and planning contributed to the facility's failure to provide adequate RN coverage, as required.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility staff failed to treat a resident with dignity and respect, as evidenced by an incident involving a resident with intact cognition, as indicated by a BIMS score of 15. The resident reported an interaction with an LPN, Staff C, who responded unpleasantly when the resident inquired about the management of the dining area. The LPN's dismissive tone and statement that managing the dining area was not her responsibility upset the resident. Additionally, a CNA, Staff E, witnessed Staff C rolling her eyes at another resident who requested pain medication, further indicating a lack of respect and dignity in interactions with residents. This behavior was contrary to the facility's Residents' Rights form, which mandates that residents be treated with respect and dignity.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility staff failed to adhere to professional standards of practice in the administration of medication for one resident. A Registered Nurse (RN), identified as Staff A, drew up a dose of liquid morphine, Roxanol, in a 1 milliliter syringe without a witness present, which is against the facility's Controlled Substances policy. This policy requires reconciliation of controlled substances upon receipt, administration, and at the end of each shift. Staff A then took the syringe to the Administrator's office, where after a dispute, the Interim Director of Nursing (DON)/Licensed Practical Nurse (LPN), identified as Staff B, took the syringe and administered the medication to the resident without direct knowledge of the syringe's contents. The incident involved Resident #1, who had been assessed to receive opioid medication as per their Minimum Data Set (MDS) assessment.
Failure to Maintain Suction Equipment Leads to Resident Incidents
Penalty
Summary
The facility failed to maintain patient care equipment in safe operating condition, specifically the suction machines, which led to critical incidents involving two residents. Resident #2, who had a do not resuscitate (DNR) status, experienced a choking incident on peanut butter crackers. During the emergency, the suction machine failed to operate, and staff had to resort to manual methods such as the Heimlich maneuver and finger sweeps, which were unsuccessful. Despite efforts from multiple staff members, including maintenance personnel, the suction machine could not be made operational in time to assist the resident effectively. In another incident, Resident #1 was reported to be drowning in her aspirations due to a malfunctioning suction machine. An investigation revealed that the machine was equipped with the wrong canister, preventing it from creating the necessary suction. This issue was identified by a nurse consultant, highlighting a critical oversight in equipment maintenance and readiness. These incidents underscore the facility's failure to ensure that essential medical equipment was in proper working order, directly impacting resident safety and care.
Delayed Reporting of Missing Narcotics
Penalty
Summary
The facility failed to report missing narcotics from the emergency narcotic lock box within the required 24-hour timeframe. A discrepancy was identified on January 15, 2025, but the facility did not report the missing narcotics to the Department of Inspections, Appeals and Licensing until January 23, 2025, at 11:51 AM. During an interview on January 23, 2025, the Interim Administrator and the current Administrator acknowledged the delay in reporting, attributing it to their ongoing investigation process. The facility had a census of 28 residents at the time of the incident.
Inadequate Assessment and Intervention for Resident's Change in Condition
Penalty
Summary
The facility failed to provide adequate assessments and interventions for a resident following a change in condition. The resident, who had a moderately impaired cognition with a BIMS score of 9, experienced severe right-side abdominal pain while sitting at the breakfast table. Despite the resident's clear signs of distress, including grimacing, labored breathing, and elevated blood pressure, the initial assessment did not include a comprehensive evaluation such as checking bowel sounds, lung sounds, or other vital signs. The resident had a history of ileus and still had his appendix, which were relevant to his condition. The facility's policy required thorough assessments and documentation every shift for residents with a change in general condition until they were stable. However, the documentation failed to meet these guidelines, as it did not include necessary assessments or interventions. The facility's administrator confirmed the expectation for staff to assess and document for three days or until the resident was asymptomatic following a condition change. The lack of comprehensive assessment and documentation in this case represents a deficiency in the facility's adherence to its own policies and procedures.
Failure to Maintain a Safe Environment for Resident
Penalty
Summary
The facility failed to maintain a safe environment for a resident when a nurse discovered a marijuana pipe and a medication bottle labeled Lasix with unknown contents in the resident's drawer. The resident, who had intact cognition and reported moderate pain, was informed by the nurse that the items could either be locked up or picked up by his daughter. The resident cooperatively stated he would not smoke there and was unsure why the items were brought. The nurse did not confiscate the items and notified another staff member, but did not have the resident's daughter's contact information to arrange for the items' removal. The clinical record lacked documentation of a physician's order for marijuana use, notification to the physician about the items, or any follow-up on what happened to the items after the initial discovery.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to administer the correct medications to a resident, leading to significant medication errors. On the specified date, a resident with intact cognition, as indicated by a BIMS score of 13, received medications intended for another resident. These medications included Benztropine mesylate, Atorvastatin, Clozapine, Cranberry, Flomax, Senokot, and Sertraline, none of which were prescribed to the resident. The error occurred when an agency nurse, unfamiliar with the residents, administered the wrong medications, mistaking the resident's identity due to similar names. Following the administration of the incorrect medications, the resident exhibited signs of sedation and was difficult to wake. The staff noted the resident's unusual behavior, such as sleeping in a chair and not responding to attempts to wake him. Despite these observations, the nurse delayed notifying the on-call doctor and did not take immediate action. Eventually, the resident was sent to the hospital due to increased respiratory rate and other concerning symptoms, where he was admitted for further evaluation. Interviews with staff and documentation revealed that the nurse did not verify the resident's identity properly and failed to follow the facility's medication administration policy, which includes the five rights of medication administration. The incident highlighted a lapse in communication and adherence to protocols, as the nurse relied on last names without realizing the presence of two residents with similar names. The facility's documentation and staff interviews confirmed the medication error and the subsequent hospitalization of the resident.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to comply with Federal Regulations requiring a Registered Nurse (RN) to be on duty for eight consecutive hours per day. A review of RN timesheets and schedules revealed that the facility did not have an RN on duty on several specific dates between January and July 2024. The facility had a census of 31 residents during this period. The deficiency was identified through a review of time cards, schedules, and staff interviews. During an interview, the Administrator admitted that the facility mistakenly believed they had a waiver for RN coverage, which led to the absence of an RN for the required hours on the specified dates.
Failure to Update PASRR for New Diagnoses
Penalty
Summary
The facility failed to submit a new Pre-admission Screening and Resident Review (PASRR) for a resident when new diagnoses were documented in the medical record. The resident's Minimum Data Set (MDS) assessment included diagnoses of depression and psychotic disorder. However, the current PASRR, dated over four years prior, did not reflect these diagnoses. The resident's medical diagnoses included major depression disorder and unspecified psychosis not due to a substance or known physiological condition, which were not updated in the PASRR. During an interview, the Administrator reported submitting the PASRR for review only after the oversight was identified, which then triggered the need for a Level II review. The facility's policy lacked specific instructions on when to submit new mental health diagnoses for PASRR review.
Deficiencies in Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to accurately complete comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #9, with intact cognition and diagnoses including arthritis and stage 3 pressure ulcers, used bed rails as a physical restraint. However, the care plan did not include the use of bed rails, despite the resident's ability to get in and out of bed independently with them. Both the Interim DON and the Administrator acknowledged that the care plan should have included bed rails, but the facility lacked a care plan policy. Resident #25, also with intact cognition, used a urinary catheter, but the care plan inaccurately addressed her as having bladder incontinence, directing staff to use disposable briefs and clean the peri-area with each incontinence episode. The Interim DON and the Administrator confirmed that the care plan should have addressed the use of a urinary catheter. Resident #28, with intact cognition, expressed feeling neglected and likened her experience to living in a jail. Her care plan lacked specific interventions for her care and treatment needs, and both the DON and the Administrator expected a comprehensive care plan to be completed within 21 days of admission, which was not done.
Failure to Revise Care Plan for Resident with Depression and Psychosis
Penalty
Summary
The facility failed to revise the care plan for Resident #11, who had documented diagnoses of major depression disorder and unspecified psychosis. The Minimum Data Set (MDS) assessment for the resident included these diagnoses, yet the current care plan lacked instructions and interventions related to these conditions. This deficiency was identified during a record review and staff interview, where it was noted that the care plan did not reflect the necessary interventions to address the resident's mental health needs. The facility had a census of 31 residents at the time of the survey.
Failure to Implement Discharge Planning for Resident
Penalty
Summary
The facility failed to implement discharge planning upon admission for a resident who expressed a desire to transfer to a different facility. The resident, who was admitted with intact cognition as indicated by a BIMS score of 13, reported feeling like a prisoner and expressed her wish to leave the facility. Despite her request, the care plan lacked a comprehensive review and interventions to facilitate her discharge to another facility. Additionally, the facility's Deaths/Discharges policy did not provide instructions on incorporating residents' wishes and goals into discharge planning. The Director of Nursing noted that the resident required 24-hour care due to her inability to care for herself at home.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to provide a qualified Infection Preventionist to oversee its infection prevention and control program. During an interview, the Administrator revealed that a Registered Nurse (RN), identified as Staff A, had completed the necessary class but had not yet taken the certification test. In a subsequent interview, Staff A confirmed that she had taken the class but had not completed the test. The facility reported a census of 31 residents at the time of the survey.
Failure to Ensure Appropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident received an antipsychotic medication, Olanzapine, only for diagnoses related to psychiatric or mood disorders upon admission. The resident, who had intact cognition as indicated by a BIMS score of 13, was admitted without documentation of psychiatric or mood disorders. An order for Olanzapine was made for the resident related to dementia without behavioral, psychotic, or mood disturbances. The resident's history and physical records lacked documentation of prior antipsychotic medication use before hospitalization. The care plan did not include a comprehensive review or interventions for the use of antipsychotic medication. The Director of Nursing was unaware that the resident was receiving an antipsychotic medication for dementia and had not taken it before admission to the facility.
Inadequate Sanitization of Blood Sugar Meters
Penalty
Summary
The facility failed to adequately sanitize the blood sugar meter and use a barrier during blood sugar checks and insulin administration for three residents. Resident #25, with intact cognition and a diagnosis of diabetes, was observed having their blood sugar checked by a Certified Medication Aide who did not clean the blood sugar meter after use. The aide placed the meter back in the medication cart without sanitizing it, despite the requirement to clean the device between each resident. Resident #10, who had moderately impaired cognition and diabetes, also received insulin and blood sugar monitoring without proper sanitization of the equipment. A Registered Nurse used a Kleenex as a barrier and failed to clean the blood sugar meter after use, placing it back in the cart without disinfection. This practice was repeated for Resident #26, who had modified independence for cognition and diabetes. The nurse again used a Kleenex as a barrier and did not clean the meter after use, returning it to the medication cart without sanitization. The Assure Prism Glucose Manufacturer's Quality Assurance/Quality Control Reference Manual and CDC guidelines emphasize the importance of cleaning and disinfecting blood glucose meters between uses to prevent the transmission of bloodborne pathogens. The facility's failure to adhere to these guidelines and the manufacturer's instructions for cleaning and disinfecting the blood sugar meters after each use led to the identified deficiencies.
Failure to Document Vaccination Education and Consent
Penalty
Summary
The facility failed to have a system in place for residents to decline vaccinations if desired, affecting three out of four residents reviewed. Resident #16's immunization history showed he received his last influenza vaccine on 10/22/21, while Resident #5's history indicated he never received an influenza vaccine. Resident #20's records showed they last received an influenza vaccine on 11/26/12. The facility's administrator reported that the Infection Preventionist (IP) did not obtain written documentation confirming that Residents #16, #5, and #20 were educated about the risks and benefits of the influenza vaccine. Additionally, the IP failed to document the residents' choices to receive or decline the vaccine. The facility's Influenza Vaccine Program requires documentation in the resident's medical record to include education about the vaccine's benefits and potential side effects, as well as whether the resident received the vaccine or the reason for not receiving it.
Inaccurate PBJ Reporting for Nursing Coverage
Penalty
Summary
The facility failed to accurately report the Payroll Based Journal (PBJ) for licensed nursing staff during the second quarter of fiscal year 2024. The PBJ report provided by the Centers for Medicare and Medicaid Services (CMS) indicated that the facility did not have licensed nurse coverage 24 hours a day, seven days a week. However, a review of the nursing timecards for the same period showed that the facility did have licensed nurse coverage 24 hours a day, seven days a week. During an interview, the Administrator admitted to submitting the PBJ incorrectly regarding the 24-hour nursing coverage, despite the facility maintaining the required coverage. The facility reported a census of 31 residents at the time of the deficiency.
Inaccurate MDS Documentation for Multiple Residents
Penalty
Summary
The facility failed to accurately document and submit the Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their records. Resident #9's MDS inaccurately coded bed rails as a physical restraint, despite the resident's ability to get in and out of bed independently. The Interim Director of Nursing (DON) and the Administrator both acknowledged that the bed rails should not have been coded as restraints. Similarly, Resident #3's MDS also incorrectly indicated the use of bed rail restraints, which did not meet the definition of a restraint according to the Resident Assessment Instrument (RAI) Manual. For Resident #20, the MDS assessment failed to document the administration of morphine, an opioid medication, during the look-back period, despite records showing its administration. The Interim DON and the Administrator confirmed that morphine should have been coded on the MDS. Additionally, Resident #29's MDS did not reflect the administration of Eliquis, an anticoagulant medication, during the look-back period, although the Medication Administration Record (MAR) indicated its use. The DON and the Administrator acknowledged that Eliquis should have been coded on the MDS.
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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