Tripoli Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Tripoli, Iowa.
- Location
- 604 Third Street Sw, Tripoli, Iowa 50676
- CMS Provider Number
- 165494
- Inspections on file
- 20
- Latest survey
- July 23, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Tripoli Nursing & Rehab during CMS and state inspections, most recent first.
A resident did not receive the necessary care and services to maintain or improve ROM, limited ROM, or mobility, and there was no documented medical reason for the decline.
A staff member responsible for laundry services routinely placed soiled linens and soaker pads directly on the floor, stood on them, and did not consistently use personal protective equipment such as gowns when handling soiled laundry. The staff member also failed to clean or cover shoes before delivering clean linens, and the facility's policies lacked clear guidance on proper containment and PPE use. Previous warnings for substandard work and missing job description documentation were also noted.
Two residents experienced disrespectful and undignified treatment by staff, including rough handling during transfers, unprofessional conversations overheard in hallways, and uncompassionate or demanding communication. One resident reported being pushed into bed by a CNA who was visibly upset, while another described staff speaking inappropriately and delaying care. These actions were confirmed through resident interviews and internal investigation, violating the facility's policy on resident rights.
A resident with moderate memory impairment and multiple health conditions reported being handled roughly by a CNA during a transfer to bed, an incident witnessed by another resident who also described the staff member as rude and inattentive. The facility's internal investigation confirmed the transfer may have been performed in a rough manner, but the required report to authorities was not made within the mandated 2-hour window, in violation of policy.
A resident with multiple chronic conditions was transported in a facility van without being properly secured in their wheelchair, as only three out of four required q-straints were used and the staff member had not received training on the van's restraint system. The wheelchair tipped backwards while going up a steep hill, prompting the staff to pull over and readjust the restraints. The facility lacked policies, procedures, and documentation related to safe transport and staff competency in this area.
Two residents with cognitive impairments experienced deficiencies in care related to dignity and respect. A resident with dementia and another with a traumatic brain injury were involved in incidents where a CNA made inappropriate comments. Despite care plans emphasizing communication and engagement, staff failed to uphold these standards, leading to deficiencies in maintaining a respectful environment.
A resident with seizure disorder and musculoskeletal impairment, requiring two-person assistance for transfers, was improperly transferred by a single CNA using a bear hug technique. Despite having a gait belt, it was not utilized during the transfer, contrary to the care plan. The facility administrator confirmed this was not the proper method.
The facility failed to store food safely, with several items found unsealed and unlabeled in the kitchen's storage and freezers. A slimy wet area was also observed in the walk-in cooler. The Administrator acknowledged these issues and confirmed the absence of a policy on food storage and labeling.
The facility failed to identify and address high-risk, high-volume, and problem-prone quality deficiencies. The Administrator admitted there was no follow-up plan for identified concerns, leading to repeated violations, including failure to transmit accurate MDS data to CMS. Despite having a QAPI Plan from 2014, the facility did not adhere to it, lacking a process to prevent recurrence of deficiencies.
The facility failed to ensure residents received a well-balanced diet due to inaccuracies in the puree process and portion sizes. Staff B, the cook, did not follow the correct procedure for measuring pureed food, resulting in incorrect portions being served. The facility administrator acknowledged the issue and noted the absence of a policy for therapeutic diets or food preparation.
The facility failed to maintain food at safe temperatures during dining service. A pan of meatloaf was left on top of the steam table, dropping from 177°F to 64°F by the last serving. Pureed fish sticks were also found at 116°F, below the required 135°F. Staff confirmed the need to hold hot foods at 135°F or above, as per facility policy.
A resident with severe cognitive impairment and swallowing issues was served an inappropriate meal that did not meet the prescribed mechanical soft diet. Despite a second check system, dietary staff failed to ensure the meal complied with the resident's dietary needs, and the facility lacked a policy for therapeutic diets.
A facility failed to complete a Significant Change MDS for a resident who was placed on hospice care, as required by the RAI Manual. Despite staff acknowledging the need for such assessments, the facility lacked a specific policy for MDS completion, leading to the oversight.
A facility failed to maintain a valid PASRR for a resident with moderate cognitive impairment and multiple diagnoses. The resident's care plan did not document the required PASRR Level II or services. The ADON admitted to not resubmitting the PASRR due to a lack of understanding of the process, and the facility lacked a PASRR policy.
A facility failed to develop a comprehensive care plan for a resident with moderate cognitive impairment and multiple diagnoses, omitting necessary PASRR Level II service recommendations. The care plan did not document these services, and the facility lacked a care plan policy.
The facility failed to complete Discharge MDS assessments for three residents upon their discharge, as required by the RAI Manual. A resident was discharged to home, another to a different facility, and a third to home, all lacking documentation of completed discharge MDS assessments. Interviews with the ADON and DON confirmed adherence to the RAI manual, which requires a Discharge MDS within 14 days post-discharge, but the facility lacked a specific MDS completion policy.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to ensure that appropriate care and services were provided to prevent a decline in these areas, except when such a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Failure to Prevent Cross-Contamination in Laundry Handling
Penalty
Summary
The facility failed to properly handle and process soiled laundry in a manner that would prevent cross transmission or the spread of infection. During observation, soiled soaker pads and bed linens were found directly on the floor in front of a washing machine, rather than being contained in the designated bin. A staff member responsible for laundry services was observed entering the laundry area from the clean side, standing directly on the soiled linens and soaker pads, and admitting that this was her usual practice. She also reported not wearing a gown when sorting soiled laundry and did not clean or cover her shoes before delivering clean linens to resident rooms. The staff member stated that she mops the laundry room floor at the end of each day and cleans the bottom of her shoes by stepping on the mop, and she is the only person working in laundry each day. Review of the staff member's personnel file revealed a lack of a signed job description for the Laundry Services position and previous documented warnings for substandard work, including not mopping the laundry room and improper handling of soiled resident clothing. The facility's Laundry Protocol policy stated that soiled linens should be handled safely to avoid contamination but lacked specific guidance on the use of gowns, gloves, and containment of soiled laundry. The Standard Precautions policy outlined the use of personal protective equipment and safe handling of potentially infectious materials but did not appear to be consistently followed in practice, as evidenced by the staff member's actions and statements.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, as required by resident rights policies. One resident, who had moderate memory impairment and required assistance with mobility and personal hygiene, reported that a CNA grabbed their upper arms and pushed them into bed during an evening shift. The resident did not report any injury but described the staff member as being rough and acting out of anger towards another staff member. The incident was not initially reported by the resident and the exact date was not recalled, but the resident confirmed the rough handling during an internal interview. Another resident, who had no memory impairment but required substantial assistance with activities of daily living, reported overhearing staff discussing inappropriate topics in the hallways and speaking to residents in a demanding and uncompassionate manner. This resident also experienced delays in care, being told to wait for repositioning because staff were conducting rounds. The resident identified specific staff members as being less compassionate and less effective when working together, and expressed that the manner in which they were spoken to was not ethical. The facility's internal investigation confirmed that concerns about staff roughness and inappropriate conversations were discussed during a resident council meeting. Interviews with the affected residents corroborated the reports of rough handling, lack of compassion, and unprofessional staff interactions. The facility's policy states that all residents are to be treated with respect and dignity, and the administrator verified this expectation during the investigation.
Failure to Timely Report Alleged Staff Roughness to Authorities
Penalty
Summary
The facility failed to report an alleged incident of staff-to-resident roughness to the Department of Inspection and Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with moderate memory impairment and multiple medical conditions, including heart failure, hypertension, diabetes, and anxiety. The resident required substantial assistance with activities of daily living, such as toileting and transfers. During an evening shift, a CNA was reported to have grabbed the resident's upper arms and pushed them into bed. The resident did not initially report the incident and could not recall the exact date, but later described the staff member as being rough, possibly due to anger directed at another staff member. The facility's internal investigation was prompted by concerns raised during a resident council meeting about staff roughness and inappropriate conversations. Interviews with the resident and another witness revealed that the CNA's behavior was perceived as rough and unprofessional, with additional complaints about the staff member's attitude and failure to provide adequate care, such as not changing the resident's clothes or properly assisting with toileting. The Director of Nursing conducted a reenactment and determined that, while the transfer was technically correct, it may have been performed in a manner considered rough or too quick by the resident. Despite these findings and the facility's policy requiring immediate reporting of all abuse allegations to DIAL within 2 hours, the facility did not notify the authorities within the mandated timeframe. The administrator confirmed this failure to report the incident promptly, which constituted a violation of both facility policy and regulatory requirements.
Failure to Properly Secure Resident in Wheelchair During Van Transport
Penalty
Summary
A deficiency occurred when a resident was not properly secured in a wheelchair during transport in the facility van, resulting in the wheelchair tilting backwards while ascending a steep hill. The resident, who had diagnoses including heart failure, hypertension, diabetes mellitus, depression, and chronic pain, was cognitively intact and required supervision or assistance with activities of daily living and mobility. During the incident, only three q-straints were used to secure the wheelchair, although the van was typically equipped with four. The staff member responsible for transport did not receive training or have access to a checklist or user manual for securing wheelchairs in the van, and was unaware of the missing fourth q-straint prior to the trip. The staff member transporting the resident noticed the wheelchair tipping back after the resident called out, prompting the staff to pull over and readjust the restraints. It was observed that the front wheels of the wheelchair were off the floor and the back was not properly secured, which contributed to the instability. The staff member later reported the incident to the DON and provided a written statement, but there was no documentation in the resident's chart, no incident report, and no follow-up recorded regarding the event. Further investigation revealed that the facility lacked policies, procedures, or guidelines for securing residents in the van with q-straints, and there was no evidence of staff education or competency checks related to this process. The administrator was unaware of the incident until informed by surveyors and confirmed the absence of relevant documentation, training materials, or a user manual for the van's restraint system.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, which compromised their quality of life. Resident #5, who has diagnoses including heart failure, hypertension, and dementia, was found to have severely impaired decision-making abilities and was dependent on staff for daily living activities. The resident's care plan included interventions to converse with the resident during care and to manage agitation. However, staff reported decreasing communication and blank stares from the resident, indicating a lack of engagement. Additionally, there was an incident involving a sexual comment made by Staff A, a CNA, which was not reported to the charge nurse as the staff felt they had managed the situation. Resident #6, with diagnoses including anemia, hypertension, and a history of traumatic brain injury, also experienced a deficiency in care. The resident had moderately impaired decision-making abilities and required assistance with daily living activities. The care plan emphasized the need for staff to converse with the resident and redirect inappropriate language. Despite this, another improper conversation involving Staff A was reported, indicating a failure to maintain appropriate communication standards. Both residents were assessed for safety and reported feeling safe, with no signs of physical abuse or changes in behavior. However, the incidents involving Staff A's conversations highlight a failure to uphold the residents' rights to dignity and respect. Staff interviews revealed a need for re-education on abuse policies and proper communication, underscoring the facility's deficiency in ensuring a respectful environment for its residents.
Improper Transfer Technique Used for Resident
Penalty
Summary
The facility failed to adhere to the care plan for a resident requiring assistance with transfers. Resident #9, who has a history of seizure disorder, epilepsy, and musculoskeletal impairment, was documented in the Minimum Data Set (MDS) as needing substantial/maximal assistance with transfers and the use of a wheelchair for mobility. The resident's Plan of Care specified that two staff members were required to assist with stand/pivot transfers every two hours and as necessary. However, it was found that the resident was transferred by a single staff member using a bear hug technique, contrary to the care plan's instructions. Interviews conducted with Resident #9 and Staff B, a Certified Nursing Assistant (CNA), confirmed that the transfer was performed by one person using a bear hug, and although a gait belt was placed around the resident's waist, it was not utilized during the transfer. The facility administrator also confirmed that the bear hug method was not the proper way to transfer the resident, acknowledging the deviation from the prescribed care plan. This incident highlights a failure in following the established protocols for resident transfers, potentially compromising the resident's safety and well-being.
Failure to Store Food Safely
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a survey. During an inspection of the kitchen's food storage and freezers, several items were found to be opened, unsealed, and lacking proper labeling to identify the product and the date it was opened. These items included a canister of butter, cottage cheese, condiments, milk, half of an apple pie, an open package of hamburger buns, a bag of stuffing, and frozen bags of chicken. Additionally, a slimy wet area was observed on the floor of the walk-in cooler. In an interview, the facility's Administrator acknowledged that these items should have been sealed, labeled, dated when opened, and discarded when necessary. The Administrator also acknowledged the presence of the slimy wet area in the walk-in cooler. Furthermore, it was revealed that the facility does not have a policy on food storage and labeling.
Failure to Address Quality Deficiencies
Penalty
Summary
The facility failed to provide satisfactory evidence of identifying and addressing high-risk, high-volume, and problem-prone quality deficiencies. During an interview, the Administrator admitted that there was no plan in place to follow up on identified concerns to ensure that previous deficiencies do not recur. A review of the facility's past survey violations revealed that the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System, and continued to be in violation without an implementation plan to correct the identified quality deficiency. The facility's QAPI Plan, dated 2014, directed a focus on systems and processes, encouraging staff to identify potential errors and system breakdowns, set goals to improve performance, measure progression toward the goal, and revise it as necessary. However, the facility did not demonstrate adherence to this plan, as evidenced by the lack of a follow-up process and continued violations.
Inaccurate Puree Process and Portion Sizes
Penalty
Summary
The facility failed to provide a well-balanced diet that met the nutritional needs of four residents, as observed during the puree process for carrots, spaghetti, and bread. Staff B, the cook, was responsible for preparing pureed meals but did not follow the established puree process correctly. Specifically, Staff B did not measure the pureed food accurately or use the puree scoop chart to determine the correct portion sizes for each resident. This resulted in inaccurate portion sizes being served at lunch. During an interview, Staff B admitted to being unaware of the proper process for measuring pureed food and acknowledged that the portions served were not accurate. Additionally, the facility administrator, Staff A, confirmed that the puree process was not completed correctly and that the facility lacked a policy for therapeutic diets or food preparation. The facility had a census of 24 residents at the time of the survey.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at a safe and appetizing temperature, as observed during dining service. On one occasion, a pan of meatloaf was left sitting on top of the steam table rather than inside it, resulting in a temperature drop from 177 degrees Fahrenheit to 64 degrees Fahrenheit by the time the last plate was served. On another occasion, pureed fish sticks were found to be at 116 degrees Fahrenheit in the steam table, below the required 135 degrees Fahrenheit. Staff interviews confirmed that hot foods should be held at 135 degrees Fahrenheit or above, and cold foods at 41 degrees Fahrenheit or below, as per the facility's policy on Cooking and Hot Holding Food. The policy emphasizes maintaining these temperatures to prevent bacterial growth in potentially hazardous foods.
Failure to Serve Appropriate Diet to Resident with Swallowing Issues
Penalty
Summary
The facility failed to provide the appropriate diet for a resident with severe cognitive impairment and a history of swallowing problems. The resident, who had a gastrostomy and required tube feedings, was evaluated by Speech Therapy (ST) and recommended a mechanical soft diet with ground meats and gravy for lubrication, along with thinned liquids under direct supervision. Despite these orders, during a dinner observation, the resident was served mechanical soft fish sticks and potato wedges that did not meet the prescribed diet requirements. The potato wedges were served with skin, and the fish sticks lacked the necessary gravy. The facility had implemented a second check of plated food by the floor nurse prior to serving, following a previous incident of aspiration by another resident. However, during the dinner service, dietary staff failed to have the nurse or staff perform this second check. The facility administrator, who was present at the time, confirmed that the food served did not comply with the mechanical soft diet orders. Additionally, the facility lacked a policy for therapeutic diets or food preparation, as verified by the administrator.
Failure to Complete Significant Change MDS for Hospice Enrollment
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment for one resident within the required 14-day period after a significant change in condition was identified. Specifically, the resident was placed on hospice care on December 29, 2023, but the necessary MDS assessment was not conducted by August 12, 2024. This oversight was identified through a review of the resident's records, which showed no completion of the Significant Change MDS following the resident's enrollment in hospice care. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that the facility follows the Resident Assessment Instrument (RAI) Manual, which mandates the completion of a Significant Change MDS when a resident enrolls in hospice. However, the facility lacked a specific policy for MDS completion, relying solely on the RAI Manual. The RAI Manual, as of October 2023, clearly states that a Significant Change MDS must be performed within 14 days of a resident's hospice election to ensure a coordinated care plan between the hospice and the nursing home.
Failure to Maintain Valid PASRR for Resident
Penalty
Summary
The facility failed to maintain a valid Pre-admission Screening and Resident Review (PASRR) for a resident with moderate cognitive impairment and multiple diagnoses, including stroke, seizure disorder, depression, and mild intellectual disabilities. The resident's Minimum Data Sample (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 12. A PASRR dated December 27, 2023, determined a Level II short-term approval ending on January 26, 2024, suggesting that the resident should return to a community setting. However, the resident's care plan, dated December 29, 2024, did not document the determined PASRR Level II or the services to be provided. During an interview, the Assistant Director of Nursing (ADON) acknowledged that the PASRR had not been resubmitted due to a lack of understanding of the process and the short-term PASRR requirements. The resident, initially intended to return to the community, had not been transitioned due to current health concerns and had accepted long-term care in the facility. The ADON also admitted to the failure to update the resident's care plan to include PASRR services. The facility administrator confirmed via email that there was no PASRR policy in place, and the facility followed regulatory guidelines.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, specifically neglecting to include Pre-Admission Screening and Resident Review (PASRR) Level II service recommendations. This deficiency was identified for one of the three residents reviewed, who had a census of 24 residents. The resident in question had a Minimum Data Set (MDS) indicating moderate cognitive impairment, with diagnoses including stroke, seizure disorder, depression, and mild intellectual disabilities. Despite these conditions, the care plan dated December 29, 2024, did not document the necessary PASRR Level II services. Additionally, the facility administrator confirmed via email that the facility lacked a care plan policy.
Failure to Complete Discharge MDS Assessments
Penalty
Summary
The facility failed to complete Discharge Minimum Data Set (MDS) assessments for three residents upon their discharge, as required by the Resident Assessment Instrument (RAI) Manual. Resident #21 was discharged to home, but a review of their MDS assessments showed no documentation of a completed discharge MDS. Similarly, Resident #77 was discharged to another facility, and Resident #78 was discharged to home, with both lacking documentation of completed discharge MDS assessments. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the facility follows the RAI manual, which mandates that a Discharge MDS must be completed within 14 calendar days after discharge. However, the facility did not have a specific policy for MDS completion, relying solely on the RAI manual guidelines.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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