Sunnycrest Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Dubuque, Iowa.
- Location
- 2375 Roosevelt Street, Dubuque, Iowa 52001
- CMS Provider Number
- 165556
- Inspections on file
- 20
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Sunnycrest Manor during CMS and state inspections, most recent first.
MDS did not accurately code a resident’s heart failure diagnosis after a hospital transfer. The resident had chest x-ray findings suggesting CHF exacerbation with pulmonary edema and a hospital discharge summary documenting acute HFpEF exacerbation, but the MDS diagnoses list did not include heart failure. The care plan also lacked direction for CHF monitoring, while the EMAR showed a daily diuretic order and daily weight monitoring for fluid retention.
Failure to Maintain Resident Nail Hygiene: A resident with mild intellectual disability, legal blindness, and altered decision-making needed partial/moderate help with personal hygiene, but staff did not keep the resident’s nails clean and trimmed as directed in the care plan. Surveyors observed brown substance under multiple fingernails on repeated checks, and the resident stated the nails still needed to be trimmed and cleaned. Staff said CNAs and nurses were expected to monitor nail hygiene on bath days and as needed.
Failure to complete updated pneumococcal vaccination for a resident with consent and a care plan directing immunizations. The resident had intact cognition, later experienced hospitalization with pneumonia and acute hypoxic respiratory failure, and the MDS listed pneumococcal status as up to date even though the EHR showed the vaccine pending. Review of notes, EMARs, and orders found no documentation of contraindications, a hold order, administration of the vaccine, or a reason it was not given; staff reported the screening was done but follow-through did not occur.
A resident with blindness and hearing impairment, dependent on a cochlear implant for communication, became agitated during a meal and was removed from the dining room by a CNA. The CNA, frustrated by the resident's behavior, removed the resident's cochlear processor, leaving the resident unable to hear until it was replaced in the elevator. This action was witnessed by staff and confirmed by the resident, constituting a failure to treat the resident with dignity and respect.
The facility failed to maintain professional standards for food storage and sanitization, with observations revealing undated and improperly stored food items, incomplete temperature logs, and inadequate sanitization practices. Staff interviews highlighted unclear responsibilities and missing documentation, contributing to the deficiencies.
The facility failed to implement effective QA activities to address kitchen-related deficiencies, including undated open foods and unsanitary food preparation. Repeated issues were noted, such as improper food labeling and lack of monitoring of refrigerator temperatures. Despite conducting audits, there was no documentation of staff education to correct these deficiencies.
A facility failed to update a care plan for a resident with anxiety, depression, and schizophrenia, who was on multiple psychotropic medications. The care plan lacked focus areas, goals, or interventions for these medications and did not monitor for side effects like involuntary movements. Staff interviews revealed that the MDS Coordinator missed entering the medications into the care plan, despite the facility's policy requiring continuous updates by the interdisciplinary team.
A resident with type 2 diabetes mellitus received insulin from an LPN who failed to prime the insulin pen as per manufacturer instructions, leading to improper administration. Nursing staff interviews revealed a lack of awareness about the priming requirement, and the Co-DON acknowledged the need to follow manufacturer guidelines.
A resident with MRSA was not provided proper infection control during wound care. An LPN failed to change gloves and wash hands between treating wounds on the resident's left heel and right great toe, contrary to the facility's infection prevention protocols. Staff interviews and facility policy emphasized the need for hand hygiene and proper PPE use, which were not followed during the observed care.
The facility failed to maintain proper food safety and hygiene standards during food preparation and service. Observations revealed undated food items, improper glove use, lack of hand hygiene, and improper utensil handling by staff, affecting multiple residents' meals.
The facility failed to maintain appropriate food holding temperatures and utilize menu-approved serving sizes. Observations revealed milk left on the counter, foods served at incorrect temperatures, and milk transported without ice. The Dietary Director was unaware of these discrepancies.
The facility failed to complete a Significant Change in Status MDS Assessment within the required time frame for a resident on hospice care. The MDS Coordinator was unaware of the 14-day requirement, and the facility lacked a specific policy, leading to the late completion of the assessment.
The facility failed to accurately code the MDS assessments for three residents, including errors in documenting hospice care, the presence of a suprapubic catheter, and insulin injections. The MDS Coordinator admitted to miscoding due to handling multiple assessments and a lack of specific policy.
MDS did not accurately code heart failure diagnosis
Penalty
Summary
The facility failed to accurately code a diagnosis on the MDS for one resident who had been transferred to the hospital. The resident’s EMR census showed a hospital transfer on 1/3/26, and the chest x-ray from that date documented findings suggesting congestive heart failure exacerbation with pulmonary edema. The hospital discharge summary dated 1/7/26 documented acute heart failure with preserved ejection fraction (HFpEF) exacerbation. However, the resident’s MDS dated [DATE] did not include heart failure in the diagnoses list, and the MDS dated [DATE] also lacked documentation of heart failure. The resident’s care plan reviewed on 3/3/26 did not provide direction to staff on monitoring for congestive heart failure. The January 2026 EMAR showed an active order for a daily diuretic medication for congestive heart failure and daily weight monitoring for fluid retention. During interview on 3/4/26, the MDS Coordinator reviewed the resident’s medical diagnoses list and the hospital discharge summary and stated that when she completed the 1/13/26 MDS, the facility had not yet received the hospital records. She confirmed the discharge summary documented heart failure and that it should have been coded on the MDS.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to provide a resident who was unable to perform activities of daily living with the services needed to maintain good personal hygiene. Resident #69 had diagnoses including mild intellectual disability, legal blindness, and altered mental status, and the MDS indicated the resident required partial/moderate assistance with personal hygiene and had moderately impaired decision-making skills for daily decisions. The care plan directed CNAs and nurses to check nail length, trim and clean the nails on bath day, and do so as necessary. During the survey, Resident #69 was observed with fingernails and toenails that still needed trimming and cleaning after a shower had been documented. On one observation, the resident stated the nails needed to be trimmed, and brown substance was noted under nails on both hands. A later observation showed the nails remained the same length, with brown substance under multiple nails on both hands and a jagged pinky nail on the left hand. The resident again reported the nails still needed to be trimmed and cleaned and stated he did not think anyone had checked them since Monday. Staff interviews indicated CNAs and nurses were expected to monitor, clean, and trim nails on bath days and as needed.
Failure to Complete Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide an updated pneumococcal vaccination for one sampled resident despite documentation showing the resident had signed consent to receive the vaccine and had a care plan directing that immunizations be administered. The resident was admitted with intact cognition, later discharged to the hospital, and subsequently returned with diagnoses including pneumonia and acute hypoxic respiratory failure. The resident’s MDS listed pneumococcal vaccination status as up to date, but the EHR immunization record showed a pneumococcal vaccine pending with a confirmation date and did not show that the updated vaccine had been given. Review of progress notes, EMARs, physician orders, and the problem list from January through early March 2026 did not show documentation of contraindications, an order to hold the vaccine, administration of an updated pneumococcal vaccine, or a rationale for why it was not administered. Staff interviews indicated the resident remained on the problem list for the vaccination and that the immunization screening had been addressed, but follow-through to complete the vaccination had not occurred. The facility’s policy required following CDC recommendations, obtaining a physician order, and administering the vaccine per manufacturer and pharmacy guidance, and the CDC schedule reviewed in the report indicated a PCV20 or PCV21 dose was due based on the resident’s prior pneumococcal vaccination history.
Resident's Hearing Device Removed During Agitation Incident
Penalty
Summary
A resident with legal blindness, hearing impairment requiring a cochlear implant, depressive disorder, and anxiety was dependent on staff for set-up assistance with eating and transfers, and used a wheelchair for mobility. The resident's care plan indicated a need for the cochlear processor to be in place with charged batteries during times of agitation and communication difficulty, as the device was essential for hearing. The care plan also instructed staff to monitor the resident's eating, encourage slow eating, and alternate liquids and solids. During a mealtime, the resident became verbally agitated and exhibited unsafe eating behaviors, such as cramming food into his mouth. Staff attempted to manage the situation by cutting up the resident's food and providing verbal cues to slow down, which further upset the resident. Staff A, a CNA, became frustrated with the resident's behavior and, while transporting the resident out of the dining room, removed the resident's cochlear processor, leaving the resident unable to hear. Staff A kept the processor in his pocket and only replaced it after less than a minute, once inside the elevator. This action was observed by another staff member and reported to nurse management. Interviews with staff and the resident confirmed that the removal of the cochlear processor occurred during the incident, and the resident recalled similar actions by the same staff member during other care activities. The facility's policy states that all residents have the right to be free from acts of personal degradation and involuntary seclusion, and the removal of the hearing device deprived the resident of the ability to communicate and participate in his environment, violating his right to dignity and respect.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitization, as observed during multiple inspections of the kitchen and dining areas. Staff were seen using a damp rag without sanitizer to clean food preparation areas, and there were no filled sanitizer buckets available. The walk-in cooler contained improperly stored and undated food items, including open and frozen milk jugs, undated juice containers, and exposed raisins. Temperature logs for refrigerators were incomplete, and some food items were stored inappropriately, such as cheese and butter left unwrapped and exposed to air. Further observations revealed that the dry storage area contained expired and improperly stored food items, such as undated chicken gravy mix and dusty containers of Caesar dressing. The area also had a vent covered in a grey, brown substance, which was not cleaned despite being identified as a priority. Staff interviews indicated a lack of clarity regarding responsibilities for monitoring refrigerator temperatures and maintaining sanitizer logs, with some staff unaware of where to find necessary documentation. The facility's policies on food storage were not followed, as evidenced by the lack of labeling and dating of open food packages and the absence of daily temperature recordings for refrigeration units. The Certified Dietary Manager acknowledged the issues but did not provide logs for sanitizer bucket checks, citing a lack of test strips. The facility's failure to maintain proper food storage and sanitization practices was compounded by inadequate documentation and unclear staff responsibilities, contributing to the observed deficiencies.
Failure to Implement Effective QA Activities in Kitchen
Penalty
Summary
The facility failed to fully implement Quality Assurance (QA) activities to address and correct kitchen-related deficiencies, as evidenced by repeated issues identified in the CMS Statements of Deficiencies. The deficiencies included undated open foods, failure to meet professional standards of food service safety, and food not being prepared under sanitary conditions. During the current survey, additional concerns were noted, such as not monitoring refrigerator and freezer temperatures, not monitoring sanitizer chemical levels, dented cans, expired food, and a dusty vent. The facility's QAPI Plan indicated that information from the Facility Assessment was used to inform the QAPI process, with the QAPI steering committee setting SMART goals each year. However, interviews with the Certified Dietary Manager (CDM) and the Administrator revealed that while audits were conducted, there was a lack of effective corrective actions and education provided to staff regarding the audit results. The CDM's audits showed that 13 out of 44 entries indicated improper labeling of food, yet there was no documentation of staff education to address these issues.
Failure to Update Care Plan for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was receiving unnecessary medications. The resident, who had intact cognition and was diagnosed with anxiety disorder, depression, and schizophrenia, was on multiple psychotropic medications. However, the care plan did not include focus areas, goals, or interventions related to these medications or the resident's mental health diagnoses. Additionally, the care plan lacked monitoring for side effects such as involuntary movements, which the resident experienced and reported during an interview. Interviews with facility staff revealed that the responsibility for updating the care plan was shared among nurses, the MDS Coordinator, and the Social Worker. The MDS Coordinator acknowledged that the psychotropic medications were not entered into the care plan, which was an oversight. The facility's policy required the interdisciplinary team to develop and update the care plan continuously, addressing resident goals, problems, needs, strengths, and preferences. However, this process was not followed for the resident in question, leading to the deficiency.
Improper Insulin Administration Technique
Penalty
Summary
The facility failed to adhere to proper insulin administration techniques for a resident with type 2 diabetes mellitus, who was prescribed Fiasp FlexTouch insulin pen. The resident's medication administration record indicated a requirement for 26 units of insulin before meals and additional sliding scale insulin based on blood sugar levels. During an observation, a Licensed Practical Nurse (LPN) administered insulin to the resident without priming the insulin pen by wasting 2 units, as per the manufacturer's instructions. The LPN used two insulin pens to deliver the prescribed dose but did not ensure the pens were functioning correctly by failing to waste the required units. Interviews with nursing staff revealed a lack of awareness regarding the necessity to prime insulin pens before administration. A Registered Nurse (RN) admitted to not knowing about the requirement to waste 2 units, while another RN mentioned priming with about 5 units. The Co-Director of Nursing acknowledged the need to follow manufacturer instructions, which were not adhered to in this instance. The package insert for the Fiasp Insulin FlexTouch Pen clearly directed the priming process, which was not followed, leading to the deficiency.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols during wound care for a resident with a history of MRSA infection. The resident had a left heel blister that was drained and tested positive for MRSA, as well as an open area on the right great toe. The care plan for the resident required contact isolation and specific hand hygiene practices to prevent the spread of infection. However, during an observation, a Licensed Practical Nurse (LPN) did not follow these protocols. The LPN double-gloved and removed soiled dressings from both the right great toe and left heel without washing hands or changing gloves between the wounds. The LPN also failed to perform hand hygiene after completing the wound care and before leaving the room, which involved touching various surfaces and equipment. Interviews with other staff members, including Registered Nurses (RNs) and the Infection Preventionist, highlighted the correct procedures that should have been followed, such as treating one wound at a time, changing gloves, and washing hands between each step of the wound care process. The facility's policy on hand washing, which was reviewed in 2024, emphasized the importance of hand hygiene before and after changing a dressing as a primary means of preventing infection transmission. Despite these guidelines, the observed actions of the LPN did not align with the facility's infection control policies, leading to a deficiency in the care provided to the resident.
Failure to Maintain Proper Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards during food preparation and service. Observations revealed that opened food items such as elbow macaroni, rigatoni noodles, and spiral noodles were undated and stored improperly. Staff B, a cook, was observed not wearing a hair net while cutting dessert bars and serving the noon meal. During the puree process, Staff A, another cook, did not change gloves after touching various surfaces and used a soiled scoop to transfer pureed carrots. Additionally, Staff B and Staff C did not perform hand hygiene between glove changes during meal service, and utensils were improperly handled, with tongs and scoops falling into food pans and being used to serve food without being cleaned. These actions affected multiple residents during meal service. The Dietary Director acknowledged the expectations for staff to wear hair restraints, wash hands between glove changes, and use utensils properly. However, the facility lacked provisions for hand hygiene on portable carts during meal service. The facility's policies on proper hand washing, glove use, and hair restraint were not followed by the staff. The undated policies directed staff to wash hands before donning gloves, change gloves when contaminated, and ensure all food handlers wear hair restraints. The failure to adhere to these policies resulted in unsanitary conditions during food preparation and service, affecting the residents' meals.
Failure to Maintain Food Holding Temperatures and Proper Serving Sizes
Penalty
Summary
The facility failed to maintain appropriate food holding temperatures and utilize the menu-approved serving sizes to meet resident nutritional needs. During an observation of the puree preparation, a milk carton was left on the counter, reaching a temperature of 49.6°F before being placed back in the refrigerator. Additionally, during the noon meal, sliced onions, pickles, and tomatoes were placed on a serving cart without ice, and various foods were served at incorrect temperatures. The scoop sizes used for serving pureed BBQ riblets, diced BBQ riblets, diced carrots, and mashed potatoes did not match the menu-approved sizes, leading to discrepancies in portion sizes. Further observations revealed that milk was not kept on ice while being transported and served to residents. A CNA removed milk from the refrigerator and placed it on a utility cart without ice, leaving it outside the dining room for an extended period before serving it to residents. The temperature of the chocolate milk served was 43.9°F, which is above the recommended holding temperature for cold foods. Interviews with the Dietary Director indicated a lack of awareness regarding the discrepancies in scoop sizes and the importance of maintaining proper food temperatures during meal service.
Failure to Complete Timely MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) Assessment within the required time frame for a resident on hospice care. Resident #2, who was admitted to hospice care for a primary diagnosis of malignant neoplasm of the colon, had an MDS assessment that did not document the hospice services in section O. The MDS 3.0 Summary Page showed that the MDS was completed late, beyond the required 14-day period after the significant change in status was identified. Staff interviews revealed that the MDS Coordinator was unaware of the requirement to complete the MDS within 14 days of identifying a significant change. The facility did not have a specific policy in place but followed the RAI manual for completing the MDS. The Co-Director of Nursing expected the RAI guidelines to be followed but deferred to the MDS Coordinator for the process. The LTC RAI 3.0 User's Manual specifies that an SCSA must be performed when a terminally ill resident enrolls in a hospice program, which was not done in this case.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents. Resident #2's MDS assessment did not document the resident's hospice care, despite the resident being on a hospice plan of care for a malignant neoplasm of the colon. The MDS Coordinator admitted to accidentally miscoding the MDS and acknowledged the lack of a specific policy, relying instead on the RAI manual for guidance. The Co-Director of Nursing expected the RAI to be followed for accurate MDS coding but deferred to the MDS Coordinator for the process details. Resident #32's MDS assessments failed to document the presence of a suprapubic catheter, instead incorrectly coding it as an ostomy. The MDS Coordinator admitted to the error and indicated the need for correction. Additionally, Resident #23's MDS inaccurately documented seven days of insulin injections, despite the absence of any physician orders for insulin. The RN/MDS Coordinator attributed this to a probable miscoding error due to handling multiple MDS assessments simultaneously.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
