West Ridge Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Knoxville, Iowa.
- Location
- 1904 West Howard Street, Knoxville, Iowa 50138
- CMS Provider Number
- 165308
- Inspections on file
- 24
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at West Ridge Specialty Care during CMS and state inspections, most recent first.
A deficiency was cited for failure to provide restorative nursing programs as care planned for three residents with mobility limitations, contractures, and cognitive or communication deficits. Therapy and care plans specified RNPs several times per week, including PROM, LE strengthening, standing in parallel bars with a gait belt, use of an omnicycle, knee brace application with skin checks, and trunk flexion exercises, but residents reported not receiving these programs and electronic documentation showed minimal or no entries beyond a single refusal. The restorative RN acknowledged that restorative programs had not been done for about a month after the restorative aide left, and multiple CNAs and the DON reported that restorative aides were routinely pulled to work on the floor, that staffing had worsened, and that restorative and bathing care were not occurring as planned. No facility policy on restorative services was provided when requested.
The facility failed to provide and document scheduled showers and baths for multiple residents who required staff assistance with ADLs, despite care plans and policies requiring such hygiene care. Cognitively intact and cognitively impaired residents with significant medical conditions, including arthritis, fractures, heart failure, renal disease, dementia, and mobility limitations, were scheduled for one or two showers or baths per week, yet electronic records showed repeated missed bathing episodes over several months without documentation of refusals or reasons. Several residents reported not receiving showers as scheduled, while multiple CNAs, a CMA, an RN, and the DON acknowledged that staffing shortages, loss of a second full‑time bath aide, lack of a dedicated bath aide on certain halls, and frequent pulling of bath and restorative aides to floor assignments resulted in residents on specific halls often receiving only one shower per week and in restorative and bathing services not occurring as planned.
A resident dependent on staff for toileting and hygiene was repeatedly left in saturated briefs and bedding for extended periods, as confirmed by multiple staff members. Staff reported that a CNA failed to complete required rounds, resulting in several residents being left wet and in soiled conditions. Despite grievances and staff reports, facility leadership did not consistently follow up or document investigations into these incidents, leading to a failure to uphold resident dignity and timely care.
A resident with multiple health conditions reported that a CNA swore at her, but the facility failed to report the suspected abuse to the state agency within the required two-hour timeframe. Despite the incident being reported to the DON later that morning, the administrative team only became aware of it the next day, indicating a delay in communication and reporting.
Failure to Provide Planned Restorative Nursing Programs Due to Staffing and Implementation Gaps
Penalty
Summary
The deficiency involves the facility’s failure to provide restorative nursing programs as care planned for three residents, resulting in a lack of implementation of ordered restorative interventions over an extended period. For one resident with intact cognition, a history of right femur fracture, limited lower extremity range of motion, and wheelchair use, therapy disciplines (OT and PT) recommended a restorative nursing program (RNP) 2–7 times per week. The recommended program included static standing in parallel bars, use of a left knee brace with skin checks, specific wheelchair leg rest positioning, seated lower extremity strengthening and reaching activities, and later additions such as use of an omnicycle, PROM to both knees, standing tolerance in parallel bars with a gait belt, and trunk flexion exercises. The resident’s care plan was revised to reflect these interventions 2–6 days per week for up to 15 minutes as tolerated. However, the resident reported not receiving restorative programs for at least two weeks, and documentation showed that the RNP had previously been marked as “resolved” and then re‑recommended, with no evidence that the newly care‑planned interventions were being consistently carried out. Another cognitively intact resident with limited upper extremity range of motion, muscle weakness, lack of coordination, reduced mobility, a history of falls, and wheelchair use was care planned for a restorative PROM program. The care plan specified use of an omnicycle for both lower extremities, PROM to the left knee and ankle, and general lower extremity exercises with a three‑pound weight on the right leg for up to 15 minutes, 2–6 days per week as tolerated. A restorative monthly review documented that this resident participated in the restorative program “as offered most days” and that goals to maintain strength and range of motion were ongoing. However, point‑of‑care documentation for the 30‑day lookback period showed “not applicable” for one date and lacked other restorative documentation, and the resident reported not having received restorative programs recently. A third resident with severe cognitive impairment, non‑Alzheimer’s dementia, arthritis, left shoulder pain, muscle weakness, a history of falls, and wheelchair dependence (requiring staff for all motion except eating) was identified on the MDS as participating in at least 15 minutes of active range of motion through a restorative program. The care plan called for an RNP to maintain strength and transfer ability and directed staff to document refusals. A restorative monthly summary stated the resident participated with encouragement and that the program continued with the current plan of care. The April documentation survey report instructed staff to complete forward leans using a basketball hoop for 3 sets of 10 repetitions, 2–6 times per week, with a Monday/Thursday schedule. The only documented entry showed a refusal on one date, with no other restorative documentation and no nursing progress notes reflecting additional refusals. Staff interviews further established that restorative programs were not being provided as planned. The restorative RN reported coordinating restorative programs for approximately 26 residents and acknowledged that restorative programs had not been done for about a month, noting that the facility’s restorative aide had left and that participation was to be documented in the EMR under point‑of‑care tasks. Multiple CNAs stated that restorative aides were routinely pulled from restorative duties to work on the floor, that staffing had worsened since early in the year, and that they themselves had not been completing restorative programs. They also reported that residents had complained about not receiving restorative services. The DON acknowledged ongoing staffing challenges, confirmed that the restorative aide left after being pulled to the floor as a CNA, and stated that staffing issues caused problems with residents receiving restorative programs, bathing, and restorative services. When surveyors requested a policy regarding restorative services, the facility did not provide one.
Failure to Provide and Document Scheduled Showers and Baths Due to Staffing Shortages
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers and baths, and to document refusals or reasons for missed care, for multiple dependent residents requiring assistance with activities of daily living (ADLs). The facility’s own ADL Support policy from March 2018 required that appropriate care and services, including hygiene and bathing, be provided in accordance with each resident’s care plan. For several residents, care plans specified staff assistance with bathing and set schedules for showers or baths, yet electronic documentation and staff and resident interviews showed that these scheduled services were not consistently provided or offered, and that missed showers were often not explained in the record. One cognitively intact resident who used a motorized wheelchair and required maximum assistance for bathing was care planned for showers twice weekly on Tuesdays and Fridays. Monthly reports showed that while all scheduled showers occurred in January, there were missed showers in February, March, and April without documentation explaining why they did not occur. This resident reported not receiving a scheduled shower on a recent Friday and stated that no one came to provide it. Another cognitively intact resident with a right femur fracture, limited lower extremity range of motion, and moderate assistance needs for bathing was also scheduled for twice-weekly showers on Tuesdays and Fridays. Documentation showed multiple missed showers in February, March, and April, with only some refusals recorded and no explanation for other missed showers. This resident stated he was supposed to receive two showers per week, felt he needed them, and reported only refusing a shower once when he had already received one the previous day. Additional residents with varying levels of cognitive impairment and extensive medical conditions, including anemia, heart failure, renal failure, Parkinson’s disease, dementia, diabetes, arthritis, and a history of falls, were also affected. One resident dependent on staff for personal hygiene and care planned as an assist of one for bathing had a bath schedule of Fridays and Sundays, but documentation showed a 10‑day gap with no recorded baths or refusals. Another severely cognitively impaired resident, reliant on staff for bathing and participating in restorative range-of-motion exercises, had a Monday/Thursday bath schedule with multiple multi‑day gaps in January, February, and March where no baths or refusals were documented. A further resident, cognitively intact but dependent on staff for bathing and with multiple cardiac and vascular diagnoses, had a Tuesday/Friday bath schedule with several multi‑day periods in January, March, and into April where no baths or refusals were recorded. Staff interviews consistently linked these missed or undocumented showers and baths to staffing shortages and the lack of a dedicated bath aide for certain halls. Multiple CNAs and a CMA acknowledged that some residents did not receive or were not offered showers as scheduled, particularly on the 300 and 400 halls, and that residents on those halls often received only one shower per week. Staff reported that there was only one full‑time bath aide after early December, that the second bath aide position remained unfilled despite attempts to use facility or agency staff, and that there was no extra staff on weekends to catch up on missed showers. Several staff members, including CNAs and an RN, stated that bath aides and restorative aides were routinely pulled to work the floor when staffing was low, resulting in bathing and restorative care not occurring as planned. The DON acknowledged ongoing staffing challenges and stated that these issues caused problems with residents receiving showers and restorative services as scheduled, despite her expectation that staff follow the care plans.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The facility failed to protect a resident's right to a dignified existence by not providing timely perineal care after episodes of incontinence. Clinical record review showed that a resident with hemiplegia, anxiety, and depression was frequently incontinent and dependent on staff for toileting hygiene. The resident was found on multiple occasions in saturated briefs and bedding, with staff documentation indicating that the resident remained in soiled conditions for extended periods. Staff interviews confirmed that this was not an isolated incident, as several staff members reported that residents assigned to a particular CNA were often left wet and required complete bed changes at shift change. Multiple staff, including CNAs, an RN, and an LPN, reported ongoing issues with the same CNA failing to complete rounds and change residents as required, resulting in residents being left in soiled briefs and bedding. Staff described finding residents with dark, wet briefs and bed pads with urine rings, and noted that rooms had persistent odors. Staff also reported that grievances had been filed regarding this CNA's conduct, and that the issue had persisted for over a year, with some staff escalating concerns to charge nurses and the DON. Despite these reports and grievances, facility leadership, including the Administrator and DON, were either unaware of recent grievances or had not followed up on them. Documentation of follow-up to grievances was lacking, and there was no evidence that audits or investigations were consistently conducted in response to staff concerns. The facility's own policy required prompt response to toileting needs and care that promoted dignity, but this was not consistently provided to the resident in question or to other residents affected by the same staff member.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to report suspected abuse to the proper state agency within the required two-hour timeframe. On the early morning of July 24, 2024, a resident with intact cognition and multiple health conditions, including anemia, coronary artery disease, heart failure, renal failure, diabetes mellitus, thyroid disorder, and chronic obstructive pulmonary disease, reported that a Certified Nurse Aide (CNA) swore at her. The resident required assistance with activities of daily living and had fallen during the shift, requiring help to get up. Despite the incident being reported to the Director of Nursing (DON) later that morning, the facility did not notify the state agency until 10:58 am, missing the two-hour reporting window. Staff B, another CNA, confirmed hearing Staff A curse at the resident but did not report the incident to the charge nurse. The administrative team only became aware of the situation the following morning, indicating a delay in communication and reporting. The facility's past non-compliance checklist noted a failure to investigate and report verbal abuse timely, and an in-service education form directed staff to report all allegations of abuse immediately to the charge nurse. The DON emphasized that staff should report any situations they are unsure about regarding abuse.
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.
