Sunny View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ankeny, Iowa.
- Location
- 410 N W Ash Drive, Ankeny, Iowa 50023
- CMS Provider Number
- 165441
- Inspections on file
- 27
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at Sunny View Care Center during CMS and state inspections, most recent first.
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 resident with MS, functional quadriplegia, anxiety, and depression was transferred to a hospital with a UTI after staff reported multiple prior incidents involving marijuana or THC products and implemented a two-person rule for care. While the resident was hospitalized and reportedly medically ready to return, facility leadership repeatedly hand-delivered emergency involuntary discharge notices without performing an in-person or coordinated assessment for readmission and relied only on existing medical records. There was no contemporaneous documentation from the PCP or MD that the resident was a danger to self or others before the discharge notices, and the facility did not document the required elements of its transfer/discharge policy, such as unmet needs, attempts to meet those needs, and detailed discharge information. The resident, her family, and hospital staff described that she wanted to return, was tearful and anxious about the discharge, and that the facility refused readmission even after an ALJ overturned the discharge. The facility also failed to obtain the resident’s or the correct POA’s signature on the discharge summary, instead having a family member of uncertain legal status sign, and did not ask the medical POA to sign when he retrieved the resident’s belongings.
Multiple residents experienced delays and unsafe conditions during transfers due to malfunctioning stand lifts with dead batteries, a bed that could not be lowered to a safe position, and a mechanical lift that tilted during use. Staff and residents reported these issues as ongoing, and maintenance was often unaware of the problems until they were formally reported, indicating lapses in equipment maintenance and reporting systems.
Two residents dependent on mechanical lifts for transfers experienced repeated delays and discomfort due to ongoing problems with lift batteries not holding a charge. One resident waited an extended period for toileting assistance and was left in soiled clothing, while another was left standing on a lift when the battery died. Staff and leadership acknowledged the persistent battery issues, and residents expressed frustration and discomfort with the situation.
The facility did not follow or document physician orders for two residents: one with heart failure and severe cognitive impairment did not consistently receive or have documentation of PRN oxygen when oxygen saturation was below 90%, and another with diabetes did not have required Hgb A1c lab tests completed or documented every six months as ordered. Staff interviews revealed confusion about orders and documentation, and review of records showed missing assessments and incomplete tracking of required labs.
The facility did not consistently follow physician orders for oxygen therapy for three residents with significant medical needs, resulting in missed or undocumented administration of PRN oxygen, incorrect oxygen flow rates, and incomplete documentation of oxygen titration. Staff were sometimes unaware of specific orders or failed to document interventions as required, and residents were observed with oxygen settings that did not match their prescribed orders.
The facility did not maintain complete and accurate medical records for two residents with moderate cognitive impairment who were involved in discharge planning. Despite family requests and ongoing discussions about transferring to other facilities, the Social Services Representative failed to document these interactions or actions in the EHR, contrary to facility policy requiring such documentation.
A resident with multiple chronic conditions and recent surgery did not receive Pyridostigmine Bromide as directed due to a failure to clarify the medication order upon admission. Despite the resident's repeated requests and pharmacy inquiries, the order was not clarified for several days, resulting in a delay in treatment. Facility staff confirmed that the order should have been clarified according to policy.
A resident's room in the facility was found to have an ammonia odor and a sticky carpet due to frequent urinal spills. Despite the resident's preference for urinal placement, the facility failed to ensure adequate cleaning. Interviews revealed that the facility's cleaning schedule was not being met, with only three rooms deep cleaned daily instead of the required six.
A facility failed to communicate and update a resident's assistance level, leading to inadequate supervision and multiple falls. Despite the resident's medical history and therapy recommendations for staff assistance, the Care Plan inaccurately listed them as independent. Staff interviews revealed confusion and inconsistency in understanding the resident's needs, contributing to the deficiency.
A resident did not receive prescribed doses of Calcium Carbonate and Voltaren External Gel as per physician's orders. The facility's records showed missed doses and delays in administration, with no care plan intervention for the Calcium Carbonate. Staff interviews revealed a lack of adherence to scheduled times and no specific policy for following physician's orders. The resident had a complex medical history and required significant assistance with daily activities.
A facility failed to assist a resident with their CPAP machine due to the absence of a physician order. The resident, who had obstructive sleep apnea, required help with the CPAP's water chamber but did not receive assistance despite requests. Staff were unaware of the equipment, and the facility lacked a policy for personal medical equipment.
The facility failed to ensure a yearly psychotropic medication gradual dose reduction (GDR) was attempted or appropriately declined for three residents. A resident with anxiety and depression was on several psychotropic medications, but the GDRs lacked clinical rationale. Another resident with bipolar disorder and psychotic disorder had GDRs for Sertraline and Risperidone without clinical rationale, and no other GDRs were found. A third resident on Escitalopram had no GDR due to the power of attorney's request, and the facility lacked a specific policy for GDRs.
A resident with complex medical conditions did not have their weight monitored as per physician's orders from March to July 2024. The facility failed to document attempts to weigh the resident, any refusals, or notify the physician of missed weights. This led to a significant weight loss and subsequent hospitalization for a UTI and sepsis. The DON acknowledged the issue and stated the facility was becoming stricter in addressing weight monitoring concerns.
A resident with moderate cognitive impairment and multiple medical conditions did not receive adequate bathing assistance as per their care plan, which required substantial assistance for showering at least twice weekly. Documentation showed only one shower was provided over several weeks, with refusals noted but no further attempts to encourage or offer bathing. Facility records lacked evidence of consistent efforts to re-approach the resident for bathing after refusals, contrary to facility policy.
A resident with severe cognitive impairment and high fall risk potentially hit their head during an unattended transfer by a CNA. Despite a witness reporting the incident, the facility failed to document necessary neurological assessments or notify the physician, focusing instead on verbal abuse allegations. The lack of documentation and follow-up resulted in a deficiency in maintaining the resident's well-being.
A resident with severe cognitive impairment and mobility issues was left unattended during a transfer by a CNA, potentially resulting in a head injury. The care plan required two-person assistance, but the CNA attempted the transfer alone. The incident was reported by a witness, but the facility failed to document or assess the event properly, focusing instead on verbal abuse allegations.
A facility failed to monitor a resident's urinary output after catheter removal, leading to inadequate assessment of urinary retention. The resident, with severe cognitive impairment, was not monitored for a week, and the staff did not document urine output accurately when the catheter was reinserted. The facility lacked a policy on monitoring urine output post-catheter removal.
A facility failed to maintain infection control for two residents with indwelling catheters. One resident's catheter bag was found on the floor, and staff did not use barriers during care. Another resident's care did not follow Enhanced Barrier Precautions, as staff failed to wear gowns. The facility's policies on catheter care and infection prevention were not adhered to, increasing the risk of infection transmission.
The facility failed to provide adequate perineal care for two residents with impaired cognition and incontinence. One resident was left on a soiled sheet despite calling for help, while another received improper perineal care, with staff not following the facility's protocol. These deficiencies highlight a lack of timely assistance and adherence to care standards.
The facility failed to respond to resident call lights within the required timeframe, affecting two residents. One resident with impaired cognition experienced delays of 30 to 45 minutes, while another with intact cognition reported a delay of over 30 minutes, causing agitation. Staff acknowledged that call lights were not answered timely due to staffing issues and individual resident needs, despite facility policy requiring a response within 15 minutes.
A facility failed to maintain a complete Care Plan for a resident with moderately impaired cognition and frequent incontinence. The resident required substantial assistance and had multiple diagnoses, but their Care Plan did not address continence status. This was confirmed by the Director of Clinical Services, despite facility policy requiring comprehensive and individualized Care Plans.
The facility failed to follow physician's orders and nursing standards for medication administration. A resident received medications late, while two others were left unattended with their medications. Staff confirmed this was a common practice, indicating a systemic issue in medication management.
A facility failed to conduct follow-up assessments for a resident with severely impaired cognition after an unwitnessed fall. The resident, who required substantial assistance and had multiple diagnoses, fell in their room without injury. Despite the facility's policy requiring 72-hour follow-up assessments, the clinical record lacked these assessments, as confirmed by the Director of Clinical Services.
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.
Failure to Assess for Readmission and Improper Involuntary Discharge Documentation
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive assessment and evaluation of a resident for readmission after a hospital transfer, and to have appropriate documentation in the medical record before issuing an involuntary discharge. The resident had intact cognition per a recent MDS, with diagnoses including progressive neurological conditions, MS, anxiety, depression, and functional quadriplegia. The MDS documented limited verbal behavioral symptoms that did not endanger the resident or others, did not significantly interfere with care or activities, and were unchanged from prior assessments. The care plan reflected the resident’s intent to remain long term and documented that she had been doing well, attending activities, and without untoward behaviors, although later entries noted her voiced discontent about staying and repeated education regarding the facility’s zero-tolerance policy for illicit substances. The record shows multiple incidents related to marijuana or THC products prior to the hospital transfer. The care plan and staff interviews documented that the resident used medical marijuana off property and that staff found three unidentifiable pills in her bed later identified as Marinol, with the resident being educated not to bring in non-prescribed medications. Another entry documented that the resident had a marijuana vape pen in her bag and admitted giving another resident a few hits, leading to re-education about illicit substances and the risks to other residents. A subsequent incident involved staff observing smoke from the resident’s mouth, a strong marijuana odor, and the resident attempting to hide a vape pen; staff reported she appeared impaired with slurred speech and rolling eyes, and the facility implemented a two-person rule for all care and contact. On a later date, the resident became unresponsive with slurred speech and was transferred to the hospital, where she was diagnosed with a UTI; facility staff reported to surveyors that they believed the UTI was complicated by THC use. After the hospital transfer, the facility did not perform an in-person assessment or evaluation of the resident at the hospital, nor did it conduct an assessment through conversations with hospital staff before serving involuntary discharge paperwork. Progress notes documented that the administrator and various witnesses went to the hospital on three separate occasions to hand-deliver emergency involuntary discharge notices, but there was no documentation of any clinical assessment for readmission or evaluation of the resident’s condition at those times. The facility relied on medical records as its assessment and later obtained a letter from the facility MD stating the resident was a danger to herself and others, but this letter was dated after the discharge notices and there was no prior documentation from the PCP or MD in the record indicating the resident was a danger. The facility also failed to follow its own admission, transfer, and discharge policy requirements for documenting the basis of transfer, specific needs that could not be met, attempts to meet those needs, and detailed discharge information. The resident, her family, and hospital staff reported that the resident was medically ready for discharge from the hospital and wanted to return to the facility, but the facility refused readmission and proceeded with the emergency involuntary discharge. The resident described receiving three separate discharge letters at the hospital, each time becoming tearful, scared, and anxious about her future and belongings, and stated she felt devastated and believed the action was related to a prior complaint she had filed. The hospital SW and coordinator corroborated that the facility declined to take the resident back even after an ALJ overturned the discharge, and that the resident was tearful, afraid, and anxious but without suicidal ideation or changes in appetite or sleep. The facility admitted another resident into the original room and locked the door after the hospital transfer. The facility also failed to obtain proper signatures on the discharge summary. The CNO stated that the resident’s mother signed the discharge summary, but the facility did not verify whether she was the POA or guardian, and the resident’s actual medical POA reported he was not consulted about the involuntary discharge and was only contacted about holding the bed at the time of hospital transfer. The POA stated the facility did not ask him to sign the discharge summary when he came to pick up the resident’s belongings. The administrator acknowledged that the resident herself did not sign the discharge summary. These actions and omissions, including the lack of comprehensive assessment for readmission, lack of required documentation supporting the involuntary discharge, and failure to obtain appropriate signatures, led to the cited deficiency and negatively affected the resident’s psychosocial well-being.
Failure to Maintain Safe and Functional Patient Care Equipment
Penalty
Summary
The facility failed to maintain mechanical and electrical patient care equipment in safe operating condition for multiple residents, resulting in delayed care and unsafe conditions. Several residents who were dependent on staff and equipment for transfers, such as those with multiple sclerosis, Parkinson's disease, and severe cognitive impairment, experienced issues with stand lifts and mechanical lifts. Specifically, two residents reported frequent problems with lift batteries dying during transfers, causing delays and leaving them in uncomfortable or unsafe positions while staff searched for working batteries. Staff and residents both confirmed that these battery issues were ongoing and not isolated incidents. In another instance, a resident's bed was found to be malfunctioning, unable to lower to the required safety position. Multiple staff members acknowledged the bed's malfunction, noting that it had been an issue for at least several days to over a week before a work order was finally submitted. The bed's inability to lower posed a safety concern, especially as the resident was dependent on staff for transfers and had a history of stroke and limited mobility. The maintenance staff only became aware of the issue after the work order was placed, despite several staff being aware of the problem earlier. Additionally, observations of two other residents being transferred with a mechanical lift revealed that one of the lift's wheels would come off the ground during use, causing the lift to tilt and creating an unstable transfer environment. Staff confirmed that this tilting had been occurring for some time, and they sometimes had to physically stabilize the lift during transfers. Maintenance staff were not aware of this issue until it was brought to their attention during the survey. Review of facility work orders indicated a lack of documentation for these recurring equipment problems, suggesting that the reporting and maintenance system was not effectively capturing or addressing all equipment safety concerns.
Failure to Maintain Resident Dignity Due to Stand Lift Battery Issues
Penalty
Summary
The facility failed to promote and maintain resident dignity for two residents who were dependent on staff and mechanical lifts for transfers and toileting. Both residents had intact cognition and required assistance for mobility and toileting due to medical conditions such as Multiple Sclerosis and Parkinson's disease. The deficiency was primarily related to ongoing issues with the batteries of stand lifts, which frequently failed to hold a charge, resulting in significant delays and discomfort for the residents during transfer and toileting activities. One resident experienced a delay of approximately 30 minutes after activating her call light to request toileting assistance. Staff attempted to use a stand lift, but the battery died during the process. After replacing the battery with another that also failed, staff had to retrieve a different lift from another part of the building. During this time, the resident remained in her wheelchair, and when finally transferred, her adult brief was saturated and drooping, indicating she had been left in soiled clothing while waiting. Staff confirmed that battery issues with the lifts had been an ongoing problem for months, causing frustration for both residents and staff. Another resident reported being left in a standing position on the lift when the battery died mid-transfer, requiring staff to leave her in that position while they retrieved a replacement battery. She described feeling uncomfortable and undignified during these episodes, which she stated occurred frequently. Facility leadership acknowledged awareness of the battery and charging issues, and resident council minutes also documented that a lift was out of commission. The facility's own dignity policy emphasized the importance of timely and respectful care, including toileting assistance and privacy, which was not upheld in these instances.
Failure to Follow and Document Physician Orders for Oxygen and Lab Monitoring
Penalty
Summary
The facility failed to follow, document, and/or carry out physician orders for two residents. For one resident with heart failure and severe cognitive impairment, there was a physician order to check oxygen saturation (POx) every shift and to apply oxygen at 2 liters via nasal prongs if the POx was below 90%. Documentation showed that on multiple occasions, the resident's oxygen saturation was below 90%, but there was no corresponding documentation that oxygen was applied as ordered. Staff interviews revealed confusion about the existence of the PRN oxygen order, and staff acknowledged not signing for the administration of oxygen when required. Additionally, there was a lack of nursing assessment documentation on days when low oxygen saturation was recorded. For another resident with diabetes and moderate cognitive impairment, there was a standing order to obtain a Hemoglobin A1c (Hgb A1c) test every six months. Review of the Treatment Administration Records (TARs) and progress notes indicated that the required Hgb A1c tests were not consistently documented as completed according to the order. The only Hgb A1c results found in the records were from a previous year and from a hospitalization, with no evidence that the six-monthly tests were performed as ordered by the physician. Interviews with nursing staff and review of facility procedures revealed that lab orders were supposed to be tracked in a Lab Order Book and on the MAR/TAR, with multiple checks in place to ensure completion. However, the process failed to ensure that the required labs were drawn and documented, and staff were unclear about the status of lab orders and documentation requirements. The facility's policy stated that all medications and treatments should be administered as ordered by a healthcare professional, but this was not followed in these cases.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that physician orders for oxygen therapy were followed for three residents. One resident with heart failure and severe cognitive impairment had a physician order for PRN oxygen to be applied when oxygen saturation fell below 90%. Documentation showed at least two occasions when the resident's oxygen saturation was 89%, but there was no documentation that oxygen was applied. Staff members reported not being aware of the PRN oxygen order, and although they sometimes applied oxygen when low saturations were noted, they did not consistently document its administration. The resident was not observed with oxygen during the survey period, and staff acknowledged not signing for PRN oxygen administration as required. Another resident with cancer, COPD, and severe cognitive impairment had a physician order for oxygen at 2 liters per nasal cannula, later changed to a titration order between 2-4 liters to maintain oxygen saturation above 90%. Observations revealed that the resident was often not wearing oxygen or had the oxygen flow set higher than ordered, sometimes at 3.5 to 4 liters instead of the prescribed 2 liters. Staff reported that the resident frequently removed the oxygen or adjusted the flow rate independently. The facility's documentation did not include a place to record the actual liter flow when titration was ordered, and staff acknowledged this gap in documentation. A third resident with multiple diagnoses, including COPD and heart failure, had an order for oxygen at 2 liters via nasal cannula, titrated to keep oxygen saturation above 90%. Observations found the resident receiving oxygen at 1.5 liters instead of the ordered 2 liters on two separate occasions. Staff present at the time acknowledged the incorrect setting and adjusted it to the correct flow rate. The facility's policy required that oxygen therapy be administered as prescribed and documented in the clinical record, but these requirements were not consistently met for the residents reviewed.
Failure to Document Discharge Planning and Family Communications in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents who were undergoing discharge planning. For one resident with moderate cognitive impairment, the care plan did not reflect a discharge plan, despite documented requests from the resident's family for referrals to other facilities. Although care conference notes indicated these requests, there were no progress notes from the Social Services Representative in the resident's electronic health record (EHR) since admission. The Social Services Representative confirmed that she had not documented any interactions or actions taken regarding the resident's transfer requests, and only provided email correspondence with the family as evidence of communication. For another resident, also with moderate cognitive impairment, care conference notes and interviews confirmed ongoing discussions between the Social Services Representative and the resident's family about transferring to a different facility. However, there were no progress notes in the EHR documenting these interactions or updates on the transfer process, with the last note being unrelated to discharge planning. The Social Services Representative acknowledged not documenting these interactions, and the Chief Nursing Officer confirmed that all such interactions should be recorded in the EHR. Facility policy required documentation of communications with residents and their representatives, as well as referrals and discharge plans, but these were not present in the records reviewed.
Failure to Clarify Medication Order Delays Resident's Treatment
Penalty
Summary
The facility failed to clarify a medication order for a newly admitted resident, resulting in a delay in the resident receiving Pyridostigmine Bromide as directed. Upon admission, the resident had a documented history of anemia, hypertension, benign prostate hyperplasia, and arthritis, and required assistance with activities of daily living following a lumbar spine fusion. The resident was cognitively intact, with no memory impairments, and was able to communicate effectively. The resident's outpatient medication list indicated Pyridostigmine Bromide 60 mg to be taken up to four times daily, but the facility's medication record listed the order as every six hours as needed for muscle spasms, which was flagged as outside the recommended frequency. Progress notes revealed ongoing confusion and concern from the resident regarding the administration of his medication, with repeated requests for clarification and a copy of his medication list. The pharmacy also requested clarification before dispensing the medication. Despite these concerns, the order was not clarified until several days after admission, during which time the resident did not receive the medication as he was accustomed to at home. The delay persisted until the provider clarified the order to match the resident's home regimen. Interviews with facility staff, including the DON and the advanced registered nurse practitioner, confirmed that the medication order should have been clarified upon admission according to facility policy. The lack of timely clarification led to the resident not receiving the prescribed medication as intended, despite multiple opportunities to address the issue and clear communication from the resident regarding his needs.
Failure to Maintain Odor-Free Environment in Resident Room
Penalty
Summary
The facility failed to ensure a homelike environment for Resident #71 by not maintaining a room free of odors. Observations revealed an ammonia odor in the hallway and Resident #71's room, despite the use of an odor diffuser. The carpet in the room felt spongy and sticky, particularly near the bed, indicating a lack of adequate cleaning. Resident #71, who has intact cognition and multiple diagnoses including anxiety, stroke, and Parkinson's, prefers to use a urinal while in bed. The resident expressed a preference for the urinal to hang on the trash can next to the bed, which sometimes results in spills when the urinal is full. Interviews with staff revealed that resident rooms are vacuumed and dusted daily, and carpets are cleaned as needed. However, there was no extra scheduled carpet cleaning for Resident #71's room despite frequent urinal spills. The Environmental Supervisor acknowledged the issue but noted that carpet cleaning relies on staff notification. The facility's Environmental Services Checklist requires each room to be deep cleaned monthly, with six rooms deep cleaned daily. However, the Environmental Supervisor estimated that only three rooms are deep cleaned daily, indicating a shortfall in meeting the facility's cleaning goals.
Inadequate Communication and Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to effectively communicate and update the current staff assistance level for a resident, leading to a deficiency in nursing supervision. The resident, who has a history of multiple medical conditions including stroke, hemiplegia, and Parkinson's, was noted to be independent in transfers and mobility according to the Care Plan. However, the resident experienced seven falls after the Minimum Data Set (MDS) was completed, indicating a potential mismatch between the resident's documented independence and their actual needs for assistance. The facility's documentation, including the Activity Level and Recommendations Form and the Physical Therapy notes, showed inconsistencies regarding the resident's required level of assistance, with some documents recommending staff assistance during transfers. Interviews with facility staff revealed a lack of clarity and communication regarding the resident's current assistance needs. Staff members were unable to consistently explain the resident's assistance level, and there was a discrepancy between the Care Plan and the recommendations from therapy. The Director of Rehab acknowledged that the Bio Worksheet did not reflect the resident's current status, given the increase in falls, and could not provide documentation for when the resident was deemed independent. This lack of communication and documentation led to inadequate supervision and contributed to the resident's repeated falls.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for a resident, leading to missed doses of prescribed medications. Specifically, the resident did not receive several doses of Calcium Carbonate (Tums) during the last week of October 2024, as documented by a Registered Nurse (RN) in the Medication Administration Record (MAR). The facility's progress notes indicated that the medication was not on hand on certain days, and there was no documentation for one of the missed doses. Additionally, the facility did not have a care plan intervention for the administration of Calcium Carbonate, and the Director of Nursing (DON) stated that staff should notify the pharmacy if stock medications are unavailable. Furthermore, the facility did not administer Voltaren External Gel as prescribed. Observations revealed that the resident did not receive the topical gel at the scheduled times, and the Treatment Administration Record (TAR) confirmed the delay. The Administration Record History (ARH) showed that the Voltaren was administered over an hour late on multiple occasions. Staff interviews indicated that there was a lack of adherence to the scheduled administration times, and the facility did not have a specific policy for following physician's orders. The resident involved had a complex medical history, including heart failure, chronic kidney disease, diabetes mellitus, chronic pain, and spinal stenosis, and required significant assistance with activities of daily living.
Failure to Assist Resident with CPAP Machine Due to Lack of Physician Order
Penalty
Summary
The facility failed to provide necessary assistance and follow-up for a resident's personal medical equipment, specifically a CPAP machine, which was needed for respiratory care. Resident #235, who had intact cognition and was admitted with conditions including obstructive sleep apnea, had a CPAP machine brought in by family shortly after admission. The resident expressed the ability to use the CPAP independently but required assistance with the water chamber. Despite the resident's requests for help, staff did not provide assistance or follow-up due to the absence of a physician's order for the CPAP. Interviews with various staff members, including registered nurses and the Director of Nursing, revealed a lack of awareness and action regarding the CPAP machine. Staff working during the day were unaware of the equipment, while a night shift nurse confirmed its presence and the resident's use of it without assistance. The facility lacked a policy addressing personal medical equipment, and the Chief Nursing Officer confirmed this absence. The Assistant Director of Nursing acknowledged the expectation for staff to recognize medical equipment and ensure physician orders are in place, highlighting a gap in the facility's procedures.
Failure to Ensure Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure a yearly psychotropic medication gradual dose reduction (GDR) was attempted or appropriately declined for three residents. Resident #32, who had multiple diagnoses including anxiety and depression, was on several psychotropic medications. The care plan directed staff to consult with pharmacy and the MD for dosage reduction quarterly, but the GDRs documented lacked clinical rationale, and no other GDRs were found in the resident's electronic health record (EHR). Additionally, the resident exhibited behaviors on specific dates, but no behaviors were documented after 12/25/24. Resident #44, diagnosed with conditions such as bipolar disorder and psychotic disorder, was also on multiple psychotropic medications. The care plan required quarterly consultation for dosage reduction, but the GDRs for Sertraline and Risperidone lacked clinical rationale, and no other GDRs were found in the EHR. The resident had no documented behaviors since 9/01/24, and the staff stated that target behaviors are documented in the Treatment Administration Record (TAR) if observed. Resident #66, with diagnoses including depression and PTSD, was on Escitalopram. The care plan included antidepressant medication use but did not provide directives for dose reductions. A GDR for Escitalopram was documented with no GDR per the power of attorney's request due to fear of increased symptoms. No other GDRs were located in the resident's EHR, and the staff was unaware of where to document target behaviors other than in progress notes. The facility did not provide a policy specific to Gradual Dose Reductions.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of quality care by not obtaining weights for a resident as per the physician's order. The resident, who had a range of complex medical conditions including neurogenic bladder, septicemia, quadriplegia, and edema, was supposed to have their weight monitored monthly. However, the facility did not record the resident's weight from March to July 2024, despite a physician's order to do so. The Treatment Administration Records (TAR) and Progress Notes lacked documentation of attempts to weigh the resident or any refusals by the resident to be weighed. Additionally, there was no documentation that the resident was educated on the risks of refusing to be weighed or that the physician was notified of the missed weights. The resident's care plan also lacked specific directions regarding weight monitoring and actions to take if the resident refused to be weighed. The facility's failure to document and follow up on the resident's weight monitoring led to a significant weight loss of 13.2% over seven months, as noted in a Dietary Quarterly Review. The resident experienced a mental status change and was hospitalized with a diagnosis of urinary tract infection and sepsis, further complicating their health status. The Director of Nursing (DON) acknowledged the issues with obtaining weights and stated that the facility was becoming more strict in addressing this concern. Despite the resident's refusal to get out of bed and be weighed, the facility's policy required that the physician be informed of any refusals, which was not done. The lack of adherence to the weight monitoring policy and failure to communicate with the physician contributed to the deficiency in care provided to the resident.
Failure to Provide Adequate Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to a resident who required substantial assistance due to moderate cognitive impairment and multiple medical conditions, including cancer, anemia, coronary artery disease, hypertension, cirrhosis of the liver, and a right humerus fracture. The resident's care plan specified the need for assistance with showering tasks at least twice weekly. However, documentation revealed that the resident received only one shower from the date of admission to early August, with several refusals noted but no further attempts documented to encourage or offer bathing. The facility's records lacked evidence of consistent efforts to re-approach the resident for bathing after initial refusals, as expected by the facility's policy. Interviews with the Assistant Director of Nursing and the Director of Nursing confirmed the absence of additional documentation for bathing attempts and highlighted the need for staff education on bathing expectations. The facility's policy required that residents receive care according to their individualized care plans, ensuring that their abilities in activities of daily living, such as showering, do not diminish unless unavoidable due to clinical conditions.
Failure to Document and Follow Up on Potential Head Injury
Penalty
Summary
The facility failed to provide necessary interventions and care for a resident, leading to a deficiency in maintaining the resident's highest practical physical well-being. The resident, who had severe cognitive impairment and required substantial assistance with daily activities, was reportedly left unattended by a CNA during a transfer, resulting in the resident potentially hitting their head on a wall. Despite a witness reporting the incident to the Director of Nursing (DON), the facility did not document the necessary neurological assessments or notify the physician as required by their policy. The resident's care plan indicated a high risk for falls due to various health conditions, including dementia and decreased mobility. The incident was reported by a family member of the resident's roommate, who witnessed the CNA verbally abusing the resident and leaving them unsupported during a transfer. The DON conducted a head-to-toe assessment but failed to document it in the clinical record, focusing instead on the verbal abuse allegations. The clinical record lacked any documentation of the incident, neurological assessments, or physician notification. Interviews with the DON and the resident's wife revealed that the facility did not follow its neurological assessment policy, which required monitoring for 72 hours after a suspected head injury. The facility's Advance Registered Nurse Practitioner (ARNP) was informed of rough treatment allegations but not specifically about the potential head injury. The facility's failure to document and follow up on the incident as per their policy resulted in a deficiency in providing adequate care and services to the resident.
Inadequate Supervision Leads to Potential Resident Injury
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident with severe cognitive impairment and multiple health conditions, including dementia and a right hip fracture. The resident required substantial assistance with activities of daily living and was at risk for falls due to confusion and decreased mobility. The care plan specified that the resident needed assistance from two staff members for transfers, but an incident occurred where a CNA attempted to transfer the resident alone, resulting in the resident potentially hitting their head against the wall. The incident was reported by a family member of the resident's roommate, who witnessed the CNA leaving the resident unattended on the bedside, leading to a loud noise that was believed to be the resident's head hitting the wall. Despite the report, the facility's documentation lacked any record of the incident or assessments conducted following the event. The Director of Nursing (DON) did not fill out an incident report, as there were no visible injuries, and focused instead on the verbal abuse reported by the witness. Interviews with staff revealed inconsistencies in the understanding and application of the resident's care plan. The CNA involved in the incident claimed that the care plan allowed for a single-person transfer with a gait belt, contradicting the care plan's requirement for two-person assistance. Other staff members confirmed that the resident had always required two-person assistance for transfers. The facility's policy on accidents and incidents emphasized the importance of reporting and documenting such events, but this was not adhered to in this case.
Failure to Monitor Urinary Output After Catheter Removal
Penalty
Summary
The facility failed to monitor and provide appropriate urinary assessment for a resident after the removal of an indwelling catheter. The resident, who had severe cognitive impairment and was unable to communicate pain or urinary needs, was not monitored for urinary retention from the time the catheter was removed until a week later when it was noted that the resident had not urinated. The facility lacked documentation of urinary assessments during this period, and the resident's condition was not adequately monitored. When the resident's catheter was reinserted, the staff did not document the urine output accurately, as required by the physician's order. The nurse reported that the urine output was close to 200 ml, but the exact amount was not recorded, and the catheter was left in place despite the order to remove it if the residual was less than 200 ml. The facility's Nurse Practitioner later stated that leaving the catheter in was appropriate given the resident's history and symptoms. The facility did not have a policy on monitoring urine output or retention after catheter removal, which contributed to the lack of proper documentation and follow-up. The Director of Nursing expected staff to follow standards of practice, document accurately, and follow physician orders, but these expectations were not met in this case. The Assistant Director of Nursing acknowledged the absence of a policy and mentioned that the Corporate Nurse was working on one.
Inadequate Infection Control for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections for two residents with indwelling catheters. Resident #5, who had a neurogenic bladder, septicemia, and a recent urinary tract infection, was observed with a catheter bag lying on the floor, contrary to the facility's policy. During catheter care, staff placed incontinence wipes directly on the turning pad without a barrier and did not ensure the catheter bag was properly positioned, leading to it lying on the floor. This resident had a history of sepsis and was readmitted to the hospital with a complicated UTI and sepsis. Resident #3, who had renal disease, heart failure, and Alzheimer's disease, was also observed receiving inadequate catheter care. Staff failed to wear gowns as required by the Enhanced Barrier Precautions policy during high-contact care activities. Incontinence wipes were placed directly on the wipe container without a barrier, and staff did not initially wear gowns, which was against the facility's policy for residents with indwelling catheters. The Director of Nursing acknowledged the expectation for staff to use appropriate barriers and wear gowns during the entire catheter care process. The facility's policies on Foley catheter care and Enhanced Barrier Precautions were not followed, contributing to the potential for infection transmission. The facility's policy emphasized the importance of preventing urinary tract infections by avoiding contact of catheter tubing with the floor and using enhanced precautions for residents with indwelling medical devices.
Inadequate Perineal Care for Two Residents
Penalty
Summary
The facility failed to provide adequate perineal care for two residents, leading to deficiencies in their care. Resident #2, with moderately impaired cognition and frequent incontinence, was found lying on a soiled sheet with a removed brief after calling for assistance. Despite her calls, staff did not attend to her needs promptly, as confirmed by her roommate and the observation of dried urine on her sheet. This indicates a failure to provide timely assistance and proper hygiene care for Resident #2, who required substantial assistance due to her cognitive and physical impairments. Resident #3, with severely impaired cognition and always incontinent, also did not receive proper perineal care. Staff members were observed providing inadequate care by not changing the washcloth surface and wiping back and forth, contrary to the facility's perineal care protocol. Additionally, during another care session, staff failed to cleanse the resident's buttocks and hips properly. These actions demonstrate a lack of adherence to the facility's protocol for perineal care, compromising the hygiene and dignity of Resident #3, who required maximal assistance due to her medical conditions.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights within the required 15-minute timeframe for two of the three residents reviewed. Resident #2, who has moderately impaired cognition and requires substantial assistance with daily activities, experienced delays of 30 to 45 minutes in call light response. Family members reported these delays and observed staff sitting at the nurse's station during these times. Resident #11, with intact cognition, also reported a delay of over 30 minutes, which caused her agitation. Staff members acknowledged that call lights were not answered timely due to staffing issues and individual resident needs. The facility's policy mandates that call lights be answered within 15 minutes for bedrooms and 5 minutes for bathrooms. However, interviews with staff and residents, as well as Resident Council Minutes, indicated ongoing concerns with call light response times. An Ombudsman email also highlighted complaints related to call light delays. Staff members admitted that approximately 10% of call lights were not answered within the required timeframe, citing staffing shortages and unexpected circumstances as contributing factors.
Incomplete Care Plan for Resident with Incontinence
Penalty
Summary
The facility failed to maintain a complete and accurate Care Plan for one of the residents reviewed. The resident, identified with a Minimum Data Set (MDS) assessment indicating moderately impaired cognition, required substantial assistance with toilet use, personal hygiene, and ambulation. The resident was frequently incontinent of bowel and bladder and had diagnoses including renal insufficiency, polyneuropathy, anxiety, and non-Alzheimer's dementia. However, the Care Plan for this resident did not address their continence status. This deficiency was confirmed through an email from the Director of Clinical Services, acknowledging the omission in the Care Plan. The facility's policy required that each Care Plan include a summary of specific goals and care needs, developed by the Interdisciplinary Team, and be reviewed and revised according to State rules, Federal regulations, and professional standards of nursing care.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to adhere to physician's orders and nursing standards of practice for medication administration, affecting three residents. For Resident #13, medications prescribed to be administered at 6 AM were given at 8:48 AM by a Certified Medication Aide. The medications included critical prescriptions such as Apixaban, Losartan Potassium, and Sotalol, among others, which are essential for managing conditions like blood pressure, heart health, and blood thinning. This delay in medication administration indicates a failure to follow the prescribed schedule, which is crucial for the effectiveness of these treatments. Additionally, the facility did not ensure proper supervision during medication administration for Residents #12 and #11. Resident #12, who has moderately impaired cognition, was left unattended with a medication cup, leading him to take his medications without supervision. Similarly, Resident #11, with intact cognition, confirmed that staff frequently left medications at her bedside unattended. Multiple staff members, including CNAs, corroborated that it was common practice to leave medications unattended, which poses a risk of medication errors or misuse.
Failure to Conduct Follow-Up Assessments After Resident Fall
Penalty
Summary
The facility failed to assess and implement interventions for a resident following a fall. Resident #3, who had a severely impaired cognition with a BIMS score of 4, required substantial assistance with toilet hygiene and was always incontinent of bowel and bladder. The resident had diagnoses of fractures, non-Alzheimer's dementia, Bell's palsy, and weakness. On 5/13/24, a progress note indicated that Resident #3 sustained an unwitnessed fall in her room at 7:30 AM without injury. However, the clinical record lacked follow-up assessments for the resident after the fall, which was expected to be conducted for 72 hours according to the facility's policy, as confirmed by the Director of Clinical Services.
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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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