Westwood Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux City, Iowa.
- Location
- 4201 Fieldcrest Drive, Sioux City, Iowa 51104
- CMS Provider Number
- 165271
- Inspections on file
- 36
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Westwood Specialty Care during CMS and state inspections, most recent first.
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.
A treatment cart was left unlocked with the computer screen on and identifiable information visible while an LPN was away from it. A Regional Consultant later shut off the screen and locked the cart, and the DON stated med carts and screens should be locked when not in use or unattended. Facility policy required the nurse to secure the medication cart during med pass to prevent unauthorized entry.
Food was not consistently served at an appetizing temperature for two residents with intact cognition. One resident reported meals were not always warm and that ice cream arrived nearly melted, while another said hot food in the dining room was usually not hot. Surveyors observed a sample tray with lemon chicken at 130 degrees and broccoli at 105 degrees, below the 135-degree minimum identified by the RD and CDM.
Failure to perform hand hygiene during catheter care was observed for two residents. A CNA completed catheter care, emptied urine collection containers, removed soiled gloves and gowns, and did not perform hand hygiene before donning new gloves or after glove removal. The CNA also handled trash items, adjusted room items, and exited the room without following the facility’s hand hygiene expectations stated by the Infection Preventionist and DON.
Staff failed to perform proper hand hygiene and follow infection control protocols during medication administration for multiple residents. An LPN and an RN were observed not cleaning hands before applying gloves, handling medications and equipment with soiled gloves, using unclean medication tools, and not disinfecting inhalers before returning them to the medication cart, contrary to facility policy.
Three residents with urinary catheters were observed with uncovered catheter bags visible from the hallway or doorway, with urine clearly seen in the bags. Facility policy requires catheter bags to be covered to maintain resident dignity, and staff confirmed this expectation.
Three residents requiring assistance with bathing did not consistently receive scheduled baths, as confirmed by clinical records, resident interviews, and staff reports. Despite care plans and facility policy mandating regular bathing, documentation showed multiple missed baths, and residents reported not being routinely offered bathing opportunities. Staff shortages and changes in bath scheduling contributed to the deficiency, with day-shift CNAs unable to complete all assigned and missed baths.
A resident with heart failure, hypertension, and coronary artery disease did not receive physician-ordered daily weights on multiple days, and there was no documentation that the physician was notified about the missed weights or that monitoring was occurring as ordered. Facility policy required such monitoring and notification, but interviews confirmed these actions were not taken.
Staff did not follow safe transfer procedures for two residents, including improper manual lifting without a gait belt and failure to lock brakes on a mechanical stand lift during transfers. Both actions were inconsistent with facility policy and equipment instructions, and involved residents requiring significant assistance due to physical or cognitive impairments.
Staff did not follow proper incontinence and catheter care protocols for two residents, including failing to clean the catheter tubing after emptying and using the same side of a wipe multiple times during peri care. Additionally, a CNA handled a resident's clothing and wheelchair with soiled gloves before performing hand hygiene, contrary to expected procedures.
A resident with cognitive impairment and chronic pain was prescribed tramadol, and discrepancies were found in the controlled drug count after a CMA failed to sign the record and two tablets were discovered missing. An LPN identified the issue during a shift change, but the CMA left the facility without explanation. The facility's medication storage policy lacked specific procedures for handling missing narcotics, and the cause of the missing medication could not be determined.
A resident with multiple medical conditions was mistakenly given another resident's medications, including jardiance and gabapentin, which were not prescribed for them. The LPN did not follow facility policy for medication administration or implement specific monitoring, such as blood glucose checks, after the error. The resident later developed new symptoms and was transferred to the emergency room after EMS found them unresponsive and with low blood glucose.
The facility did not document significant incidents in the medical records for two residents, including missing money and missing medication. Despite facility policy requiring documentation of such events, these incidents were not recorded by licensed staff.
Staff did not provide complete incontinence care for a resident with severe cognitive impairment, failing to fully cleanse the buttocks and not using separate wipes for different areas as required by policy. Additionally, hand hygiene was not performed between glove changes, resulting in a lapse in infection control practices.
The facility inaccurately submitted staffing reports to CMS for Quarter 1 of 2025, resulting in a one-star staffing rating due to excessively low weekend staffing. Although floor staffing was consistent throughout the week, management staffing decreased on weekends. The Administrator admitted to inaccuracies in reporting the hours of the MDS Coordinator and the DON, who occasionally worked weekends. The facility's policy required accurate electronic reporting based on payroll records, which was not followed.
The facility failed to update care plans for several residents, missing critical information on high-risk medications, PASARR recommendations, oxygen usage, and fluid restrictions. A resident's care plan lacked details on antipsychotic and opioid medications, while another's did not address oxygen and fluid restrictions. Additionally, a resident's care plan did not include fall prevention interventions, and another's failed to incorporate PASARR recommendations.
The facility was found deficient in food preparation and hygiene practices. Observations revealed unclean kitchen drawers with debris and improper glove use by a staff member during food handling. The Certified Dietary Manager acknowledged the need for cleanliness and proper glove use, as outlined in the facility's policies.
The facility did not have the required members present at a QAA meeting, as shown by a missing signature on the sign-in sheet. The policy requires the presence of the Administrator, DON, Medical Director, Infection Preventionist, and other department representatives. An interview with the Administrator confirmed the deficiency.
The facility did not ensure that a Registered Nurse maintained current mandatory reporter training, resulting in a lapse in training on recognizing and reporting abuse, neglect, and exploitation. Despite the facility's policy emphasizing the importance of staff education, the RN continued to work with an expired training certificate, which was acknowledged by the Administrator.
The facility did not follow the prescribed menu, failing to provide wheat rolls with meals and consistently serving lukewarm food. A resident reported missing items, such as grape juice, from her meals, with no alternatives provided.
The facility failed to serve food at appetizing temperatures, as reported by several residents with intact cognition. Residents complained about receiving cold food, and staff interviews revealed that the hot plate warmer had been non-functional for almost a year. Observations confirmed that food temperatures were below expected levels, and staff acknowledged frequent complaints, particularly regarding room trays. The facility's policy on maintaining proper food temperatures was not followed.
The facility failed to follow infection prevention practices, particularly in using PPE for residents requiring Enhanced Barrier Precautions. A resident with a dialysis port reported staff not wearing gowns during personal care, and observations confirmed this. Another resident with a feeding tube received care without PPE, and an LPN placed medication on a bed without a barrier. These actions violated the facility's infection control policies.
A resident in a LTC facility, with no cognitive impairment, requested baths four times a week as recommended by their doctor. However, facility records and staff interviews revealed inconsistencies, with the resident receiving showers only four times over a month. The CNA noted the resident preferred baths at night, but aides were reluctant. The DON and Administrator were unaware of the resident's request, leading to a deficiency in providing adequate bathing care.
The facility failed to maintain accurate medical records for two residents. One resident's hearing aids were not documented on the inventory list, and a missing hearing aid was not recorded in the EHR. Another resident's fall incident was not documented in the progress notes, despite an incident report being created. Staff interviews confirmed these documentation lapses.
A resident with a history of unsteadiness and repeated falls experienced three fall incidents due to inadequate supervision and failure to use gait belts during transfers. Despite the facility's policy requiring gait belt use, staff did not consistently apply this measure, leading to the resident's knees buckling and subsequent falls. The care plan lacked interventions to prevent further falls, contributing to the deficiency.
The facility failed to follow physician's orders for two residents, leading to lapses in care. One resident did not receive prescribed antibiotics on time, and the order for specific incontinence care products was delayed. Another resident, requiring oxygen therapy, had no documented order in the MAR or TAR, resulting in low oxygen saturation and hospitalization. Issues with the EHR system and staff oversight contributed to these deficiencies.
A resident with multiple health conditions did not receive adequate assistance with denture cleaning and perineal hygiene, leading to severe excoriation and unclean dentures. Despite care plans indicating the need for assistance, facility staff failed to provide consistent care, resulting in significant hygiene issues observed by hospital staff.
A facility failed to resubmit the PASRR for a resident after a 180-day short stay approval expired. The resident had multiple diagnoses, including depression and PTSD, and a BIMS score indicating no cognitive impairment. The subsequent PASRR Level I Determination lacked documentation of the resident's active diagnosis of anxiety, ongoing behavioral health services, and homelessness. The facility did not have a PASRR policy, and an interview confirmed the oversight.
A facility failed to follow and document physician orders for a resident's ankle support devices. The resident, with no cognitive impairment, was unsure about the use of a cam boot and ankle brace. Staff interviews revealed a lack of knowledge about the devices' usage, and the DON confirmed missing physician orders. Orthopedic notes indicated a plan for the resident to use a lace-up ankle brace and wean off the boot, but these were not documented in the facility's records.
The facility failed to notify the PCP of a worsening DTI for a resident and delayed wound care treatment for another resident's newly identified DTI. One resident's injury almost doubled in size without PCP notification, while another resident returned with a DTI but lacked specific treatment orders for over a week. The DON and Regional Nurse Consultant acknowledged these oversights.
A facility failed to update a diet order for a resident with severe cognitive impairment and a pressure injury. Despite a recommendation from the RD to discontinue a small portions diet due to significant weight loss, the diet order was not updated as discussed in a Standards of Care meeting. The resident continued on a small portion diet, contrary to the recommendations.
A facility failed to follow the prescribed oxygen order for a resident with complex medical conditions, including chronic respiratory failure. The resident's care plan was updated, but discrepancies in oxygen settings were observed, with the resident receiving higher levels than the continuous 2L order. The previous as-needed order was not removed, leading to both orders being listed on the TAR. Interviews revealed that staff were inappropriately directed to include a buffer in oxygen amounts, resulting in a failure to adhere to the prescribed therapy.
The facility failed to ensure the manual can opener blade in the kitchen was clean, posing a risk of bacteria growth and cross-contamination. Despite daily cleaning logs, the blade was not properly cleaned, as confirmed by the Certified Dietary Manager and Registered Dietitian. The facility's sanitation policy requires thorough cleaning of all equipment parts, which was not followed in this case.
In a LTC facility, staff failed to follow proper hand hygiene protocols for two residents. A CNA did not perform hand hygiene after removing PPE following catheter care for a resident with severe cognitive impairment. An LPN used the same gloves for repositioning and medication administration for a bed-bound resident with a PEG tube, violating the facility's Enhanced Barrier Precautions policy.
A facility failed to ensure a resident's call light was within reach, as observed on multiple occasions. Despite the facility's policy requiring call lights to be accessible, the resident's call light was consistently placed out of reach. A Regional Nurse Consultant confirmed the expectation for accessibility.
A facility failed to provide a written bed hold notice to a resident and their responsible person after a verbal consent was given during a hospital transfer. The resident, with heart failure, diabetes, and asthma, was unaware of the bed hold cost upon re-admission. The facility's policy requires written notice, but none was sent, as confirmed by the Business Office Manager.
The facility failed to ensure safety measures for three residents, leading to potential hazards. A resident was transferred using a mechanical lift without locking wheelchair brakes, another was ambulated without a gait belt or proper footwear, and a third experienced a fall from a high bed position. The facility lacked specific policies and documentation to prevent these incidents.
A resident with multiple medical conditions and a care plan requiring close monitoring for skin changes was found to have an unreported open wound on her ankle. Despite previous documentation and communication about a blister, the wound was not reported to nursing staff, indicating a lapse in following professional care standards.
The facility failed to reposition two residents according to their care plans. One resident with a pressure ulcer was observed lying on her back for extended periods despite orders to be positioned on her side. Another resident, severely impaired and dependent on staff, was frequently left sleeping in her wheelchair without repositioning, contrary to her care plan.
The facility failed to use adequate infection control measures for two residents, leading to potential risks of pathogen spread. One resident had a urinary catheter bag mishandled by a CNA without gloves, and another resident received incontinence care from CNAs who did not follow proper hygiene protocols.
A nursing home faced deficiencies in implementing effective fall prevention interventions for a resident with moderately impaired cognitive skills and a history of repeated falls. The resident experienced multiple falls resulting in injuries, including rib and hip fractures. Despite documented risk factors such as confusion and impaired memory, the facility's interventions, including educational reminders to seek assistance, were insufficient. Incident reports and staff interviews revealed inconsistencies in assessing the resident's cognitive status and care planning, highlighting gaps in the facility's adherence to its Falls and Fall Risk Management policy.
The facility failed to answer call lights within 15 minutes for multiple residents, with delays ranging from 30 minutes to 1.5 hours. An LPN confirmed that call lights are not answered timely during weekends due to short staffing. The DON expected call lights to be answered within 15 minutes, but this was not consistently achieved.
The facility failed to sustain an effective QAPI program, resulting in repeated violations related to resident rights, professional standards, ADL care, quality of care, accident hazards, respiratory care, sufficient nursing staff, nutritional value of food, frequency of meals, food procurement and sanitation, and resident records. Despite having a QAPI committee and following plans of correction, the facility's interventions were insufficient to resolve the issues.
The facility failed to complete proper hand hygiene during incontinence care for two residents and did not pass food in a sanitary manner. Staff members did not change gloves or perform hand hygiene at appropriate times, and food was handled with bare hands instead of utensils. The Director of Nursing and Corporate Dietitian confirmed these practices were against facility policies.
The facility failed to respect the dignity of a resident with impaired cognition, did not provide privacy during perineal care for another resident, and did not honor a third resident's request for three baths a week despite a physician's order. These actions violate the facility's policies on resident dignity and rights.
A resident with cancer and anemia experienced significant weight loss due to frequent refusals of prescribed supplements. The facility failed to notify the physician of these refusals, and the care plan lacked information on the use of nutrition supplements. The Director of Nursing confirmed that the nurse should notify the physician if a supplement did not work for a resident.
The facility failed to ensure that residents and their families could file grievances without fear of reprisal and did not follow up on all grievances. A family member reported filing a grievance about her mother not receiving a scheduled bath, but the facility did not follow up on this grievance, and it was not found in the grievance binder.
The facility failed to refer a resident with severe cognitive impairment and significant behavioral changes for a Level II PASRR evaluation. Despite multiple instances of agitation and combativeness, and the administration of psychiatric medications, the PASRR was not updated, and the care plan lacked specific behavioral interventions.
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.
Unsecured Medication Cart With Visible Identifiable Information
Penalty
Summary
The facility failed to properly secure and store medications to minimize loss or access for 1 of 4 medication carts. During continuous observation on 4/19/26 at 2:12 PM, a treatment cart was left unlocked with the computer screen on and identifiable information visible on the screen for 4 minutes while Staff D, an LPN, was away from the cart. Staff C, the Regional Consultant, then came down the hall, shut off the computer screen, and locked the treatment cart. During interview on 4/21/26 at 8:46 AM, the DON stated she would have liked to have seen the med carts locked and the computer screen locked when not in use or when staff are not around. Review of the facility policy titled Security of Medication Cart, revised April 2007, indicated the nurse must secure the medication cart during medication pass to prevent unauthorized entry.
Food Served at Inadequate Temperatures
Penalty
Summary
Food and drink were not consistently served at an appetizing temperature for 2 of 15 residents reviewed, including Resident #3 and Resident #94, both of whom had BIMS scores of 15 indicating intact cognitive functioning. Resident #3 stated that food was not always warm and reported that ice cream ordered from the facility was almost the consistency of chocolate milk. Resident #94 stated that hot food was never hot in the dining room, except on the day of interview, and that there had only been one other time when the food had been hot. During observation of room tray preparation and delivery, a sample tray was checked and the lemon chicken measured 130 degrees and the broccoli measured 105 degrees. The Regional Dietician stated that food should be warmer when served and at a minimum of 135 degrees, and the CDM stated that she would like to see food served at 135 degrees or warmer. The facility policy stated that proper hot and cold temperatures are maintained during food service and distribution.
Failure to Perform Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to provide proper hand hygiene during catheter care for 2 of 3 residents reviewed, including Resident #12 and Resident #15. During observation on 4/21/2026 at 11:07 AM, Staff J, a CNA, completed catheter care for Resident #12, emptied and rinsed the urine collection containers, removed the gown and soiled gloves, and did not perform hand hygiene. Staff J then handled the trash bag, removed a roll of garbage bags from the bottom of the trash container, placed the roll into a basket behind the sink, put a new bag into the receptacle, shut off the bathroom light, opened the resident’s door, obtained hand sanitizer with one hand, rubbed the sanitizer across that hand, and entered the locked utility room. During observation on 4/22/2026 at 9:35 AM, Staff H, a CNA, completed catheter care for Resident #15, removed soiled gloves and did not perform hand hygiene before donning new gloves. Staff H then emptied the urine collection containers, removed the gown and soiled gloves, and again failed to perform hand hygiene. Staff H adjusted the resident’s bedside table, opened the resident’s door, and exited the room. The facility’s Hand Hygiene Policy, last updated in August 2019, identified hand hygiene as required immediately before donning and doffing gloves. The Infection Preventionist stated staff are expected to perform hand hygiene prior to putting on gloves, immediately after removing gloves, and when leaving the resident’s room, and the DON stated she expected staff to perform hand hygiene immediately before applying gloves and when gloves are removed.
Failure to Follow Hand Hygiene and Infection Control During Medication Pass
Penalty
Summary
Facility staff failed to perform proper hand hygiene and adhere to infection control guidelines during medication administration for four observed residents. Specifically, a Licensed Practical Nurse (LPN) did not perform hand hygiene before applying gloves, handled insulin and medication packaging with gloved hands, and touched various surfaces, including the computer screen and medication drawer, without changing gloves or performing hand hygiene between tasks. The LPN also picked up a dropped medication from the top of the medication cart with a gloved hand, without prior hand hygiene, and placed it into a medication cup for administration. Additionally, a Registered Nurse (RN) used a visibly soiled pill cutter without cleaning it, handled medications and equipment without performing hand hygiene before or after glove use, and failed to clean or disinfect a resident's inhaler after use, returning it to the medication cart without wiping it down. These actions were inconsistent with the facility's policies on administering medications and hand hygiene, which require hand hygiene before and after handling medications, before applying gloves, and after removing gloves. Interviews confirmed that staff were expected to follow infection control measures at all times.
Failure to Cover Catheter Bags Compromises Resident Dignity
Penalty
Summary
Surveyors observed that three residents with urinary catheters had their catheter bags uncovered and visible from the hallway or doorway while lying in bed. These observations occurred at various times, with urine clearly visible in the bags, and no privacy covers in place. Review of the facility's policy on dignity, revised in February 2021, indicated that staff are expected to help residents keep urinary catheter bags covered to promote dignity and prohibit demeaning practices. An interview with the Regional Nurse Consultant confirmed that all catheter bags should have covers due to dignity concerns.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled bathing assistance to three residents who required help with activities of daily living, specifically bathing. Clinical record reviews, resident interviews, and documentation revealed that these residents did not consistently receive their scheduled baths, despite care plans indicating the need for assistance. For example, one resident with muscle wasting and repeated falls was scheduled for baths twice weekly but only received two baths in November and none in the first 20 days of December. Another resident with dementia and Parkinson's disease, also scheduled for twice-weekly baths, missed several scheduled bathing dates in both November and December. A third resident, requiring substantial assistance due to unsteadiness and repeated falls, similarly missed multiple scheduled baths over the same period. Resident interviews confirmed that baths were not consistently offered as scheduled, with some residents expressing distress or dissatisfaction about missed baths. While some residents occasionally refused bathing, documentation and interviews indicated that refusals were not the primary reason for the missed baths. Instead, residents reported that they were not routinely offered the opportunity to bathe according to their care plans, and in some cases, could not recall being offered a bath at all on certain dates. Staff interviews revealed operational issues contributing to the deficiency. A CNA reported that recent staff resignations and changes in the bathing schedule, including shifting some baths to the night shift, resulted in residents not receiving their scheduled baths. The CNA stated that night-shift baths were often not completed, and day-shift staff were expected to compensate for missed baths in addition to their regular duties, leading to further lapses. The facility's policy required documentation of bathing, including refusals and interventions, but records showed incomplete adherence to these requirements.
Failure to Complete Physician-Ordered Daily Weights and Notify Physician
Penalty
Summary
The facility failed to provide physician-ordered daily weights for a resident with heart failure, hypertension, and coronary artery disease. The resident's Minimum Data Set (MDS) indicated no cognitive impairment, and the physician's order specified daily weights if there was a weight gain of more than 3 pounds in one day or more than 5 pounds in one week, with weekly faxing of weights. However, daily weight records showed multiple missed days over a three-month period, and there was no documentation that the physician had been notified about the missed weights or that the monitoring was occurring as ordered. Facility policy required supervision of medical care, including monitoring changes in residents' medical status and overseeing relevant care plans. Interviews confirmed that daily weights should have been completed and the physician notified if they were not.
Failure to Ensure Safe Resident Transfers and Use of Transfer Equipment
Penalty
Summary
Staff failed to provide safe transfers for two residents, as observed during surveyor visits. In one instance, a CNA assisted a resident with toileting by pulling the resident up to a standing position using her forearm under the resident's armpit, rather than using a gait belt as required by facility policy. The resident's care plan indicated a need for one-person assistance with toileting and personal hygiene, and the MDS assessment showed the resident was dependent on staff for toileting and required partial to moderate assistance with transfers. Facility policy specified that staff should use appropriate techniques and devices, such as gait belts, for lifting and moving residents, and staff were expected to be trained in these procedures. In another case, a CNA used a mechanical stand lift to transfer a resident with severe cognitive impairment and multiple diagnoses, including seizure disorder and COPD. The CNA failed to lock the lift brakes before raising the resident from the toilet and again before lowering the resident into a wheelchair, contrary to the operator's manual instructions. The resident's care plan required the use of a mechanical stand lift with one-person assistance for transfers. The administrator confirmed that staff should follow the operator's manual when using the mechanical stand lift.
Failure to Provide Proper Incontinence and Catheter Care
Penalty
Summary
Staff failed to provide complete and appropriate incontinence and catheter care for two residents. In one instance, a CNA emptied a resident's catheter bag, cleaned the catheter end prior to emptying, but after emptying the urine, closed the end and placed it back into the bag without cleaning it again. The CNA then cleaned up supplies, removed gown and gloves, and performed hand hygiene, but did not follow proper protocol for cleaning the catheter tubing after emptying. In another instance, a CNA assisted a resident with toileting and peri care but used the same side of a disposable wipe multiple times to clean both the perineal area and rectum, increasing the risk of contamination. The CNA also pulled up the resident's brief and clothing and adjusted her sweater while still wearing soiled gloves, only removing gloves and performing hand hygiene after the resident was back in her wheelchair. The Regional Nurse Consultant confirmed that staff are expected to use a clean part of the wipe for each stroke and to use an alcohol swab after emptying catheter tubing.
Failure to Maintain Accurate Controlled Medication Records and Investigate Missing Narcotics
Penalty
Summary
The facility failed to provide and maintain accurate records regarding a controlled medication incident involving a resident with muscle wasting, nerve damage, and moderate cognitive impairment who was prescribed tramadol for pain management. On the date in question, the Controlled Drug Count Record was not signed by a Certified Medication Assistant (CMA) at 6 AM, and a subsequent count revealed that two tramadol tablets were missing. The Individual Narcotic Record and Medication Reconciliation indicated discrepancies in the tramadol tablet count between shifts. Staff interviews confirmed that after the administration of bedtime medications, a Licensed Practical Nurse (LPN) assumed responsibility for the medication cart and discovered the missing tablets during the narcotic count with the CMA, who then refused to sign the count record and left the facility immediately. The facility's policy on the storage of medications did not include specific procedures for narcotic counting, destruction, or actions to be taken in the event of missing medication. The Regional Nurse Consultant confirmed the loss of two tramadol tablets and reported that the facility was unable to determine the cause of the missing medication. The investigation concluded without resolution as the CMA involved did not return to the facility or respond to follow-up attempts.
Significant Medication Error and Inadequate Monitoring After Wrong Medication Administration
Penalty
Summary
A resident with diagnoses of heart failure, renal insufficiency, and stroke, and no cognitive impairment, was administered another resident's medications, specifically jardiance and gabapentin, which were not ordered for them. The error occurred during the morning medication pass, and the resident spat out most of the medications due to swallowing issues but ingested at least two or three pills, including a diabetic medication. The LPN involved did not recall all the medications ingested but identified one as a diabetic medication. The nurse did not receive or implement specific monitoring parameters from the provider, such as checking blood glucose levels, and did not document all assessments performed after the error. Later that day, the resident exhibited increased drowsiness and new stroke-like symptoms, prompting emergency medical services to be called. Upon EMS arrival, the resident was found to be unresponsive to verbal stimuli, diaphoretic, and hot, with a blood glucose level of 64 mg/dL. Facility policy required verification of resident identity and medication checks prior to administration, which were not followed in this instance. The medication error and subsequent lack of thorough monitoring and documentation contributed to the resident's acute change in condition and transfer to the emergency room.
Failure to Document Resident Incidents and Missing Medications
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents in relation to significant incidents. For one resident with diagnoses including muscle wasting, repeated falls, and disorientation, there was no documentation in the medical record regarding the reported disappearance of $105 from a pouch attached to the resident's walker. The resident, who had no cognitive impairment according to the BIMS assessment, reported the missing money to the Administrator after returning from the hospital, but this event was not recorded in the resident's records. For another resident with muscle wasting, wheelchair dependence, nerve damage, and moderate cognitive impairment, staff discovered two missing tramadol tablets during a narcotic count. Despite this, there was no documentation in the resident's medical record regarding the missing medication. The facility's own Charting and Documentation policy requires that all incidents, changes in condition, and events involving residents be documented in the medical record, but this was not followed in these cases.
Incomplete Incontinence Care and Infection Control Lapses
Penalty
Summary
Staff failed to provide complete and appropriate incontinence care for a resident with severe cognitive impairment and multiple diagnoses, including stroke and dementia. During observed care, staff performed some steps of perineal care according to policy, such as hand hygiene and use of gloves, but did not fully cleanse the entire surface area of the resident's buttocks. Additionally, one staff member used different areas of the same cleansing wipe to clean the buttocks, rather than using a new wipe as required by facility policy. Another staff member failed to perform hand hygiene after removing gloves and before donning new gloves to apply a clean brief. Facility policy specifies the use of separate wipes for different areas during perineal care and emphasizes thorough cleansing to prevent infections and skin irritation. The Regional Nurse Consultant confirmed that staff are expected to use a different wipe for the groin, front perineal, penis, and urethral areas. The observed deviations from policy during incontinence care did not align with these requirements, resulting in incomplete care and a failure to follow established infection prevention protocols.
Inaccurate Staffing Reports Submitted to CMS
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for Quarter 1 of 2025. The report, run on March 13, 2025, indicated excessively low weekend staffing and resulted in a one-star staffing rating. Upon review, it was found that the facility maintained equal floor staffing during the week and weekends, but management staffing decreased on weekends. The Administrator acknowledged that more management staff, including two Assistant Directors of Nursing (ADONs) and a Director of Nursing (DON), were present during weekdays, and the Minimum Data Set (MDS) Coordinator's hours were inaccurately reported as floor staffing. Additionally, the DON occasionally worked on weekends to cover call-ins, but her hours were reported inaccurately. The facility's policy, revised in October 2017, required staffing and census information to be reported electronically to CMS, based on payroll records or other verifiable information, but this was not adhered to accurately.
Deficiencies in Care Plan Updates and Implementation
Penalty
Summary
The facility failed to revise and update care plans for several residents, leading to deficiencies in addressing high-risk medications, PASARR recommendations, oxygen usage, and fluid restrictions. For Resident #20, the care plan did not include information on the use of antipsychotic and opioid medications, their side effects, or non-pharmacological interventions for anxiety and depression. This oversight occurred despite the resident being prescribed multiple high-risk medications, including sertraline, morphine sulfate, haloperidol, and lorazepam. Resident #72's care plan was also found lacking, as it did not address the resident's oxygen usage and fluid restriction, despite the resident being observed wearing oxygen and having orders for oxygen management and a fluid restriction of 1500 ml per day. The care plan dated prior to these orders did not reflect these critical aspects of the resident's care needs. Additionally, Resident #231's care plan did not include interventions to prevent further falls, even though the resident had experienced multiple falls. The care plan for Resident #45 failed to incorporate PASARR Level II Outcome recommendations, which are necessary for compliance and to address the resident's specialized and rehabilitative service needs. The Director of Nursing acknowledged these deficiencies, indicating a lack of comprehensive, person-centered care planning as per the facility's policy.
Food Preparation and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards in food preparation, service, and distribution, as observed during a survey. During an initial kitchen walkthrough, multiple dark-colored stains and miscellaneous debris were found inside drawers near the coffee machine, along with lids for cups and straws. Additionally, a staff member, identified as Staff P, was observed improperly handling food by using the same gloved hand to open a bag of buns and place a bun onto a plate for service without changing gloves. The Certified Dietary Manager (CDM) confirmed that the kitchen area and drawers should be clean and that staff should change gloves at appropriate times. The facility's policies on sanitization and food preparation emphasize maintaining cleanliness and proper hygiene to prevent foodborne illness, which were not followed in these instances.
QAA Meeting Lacked Required Members
Penalty
Summary
The facility failed to meet the required composition for their Quality Assessment and Assurance (QAA) meetings, as evidenced by a review of the meeting sign-in sheet dated November 12, 2024, which lacked the signature of one required staff member. The facility's policy, revised in March 2020, mandates that the QAA committee include the Administrator, Director of Nursing, Medical Director, Infection Preventionist, and representatives from other departments as needed. An interview with the Administrator confirmed that the appropriate number of staff should have been present at the meeting, indicating a deficiency in meeting the regulatory requirements for QAA meetings.
Failure to Maintain Current Mandatory Reporter Training
Penalty
Summary
The facility failed to provide adequate training to their staff on recognizing and reporting abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified through policy review, document review, and staff interviews. Specifically, Staff B, a Registered Nurse, had an expired mandatory reporter training certificate, which was not renewed before its expiration. Despite this, Staff B continued to work at the facility without current training. The facility's policy emphasized the importance of staff education and training in preventing abuse, yet the expectation for mandatory reporter training to be completed before expiration was not met. The Administrator acknowledged the lapse in training for Staff B, who was suspended, and confirmed that the training was not updated during the suspension period.
Failure to Follow Menu and Meet Nutritional Needs
Penalty
Summary
The facility failed to adhere to the prescribed menu and adequately meet the nutritional needs of 19 out of 81 residents. During an observation on March 25, 2025, it was noted that the first 18 plates served in the dining room did not include wheat rolls, which were part of the planned menu for that day. The Certified Dietary Manager confirmed that the expectation was for menus to be followed. Additionally, a resident with no cognitive impairment reported consistently receiving lukewarm food and missing items from her meals. On the morning of March 17, 2025, she did not receive the grape juice she had selected on her menu, nor was she provided with an alternative.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to several residents, as evidenced by interviews and observations. Resident #28, with intact cognition, reported that the food was often cold when it should be hot. Similarly, Resident #36, also with intact cognition, mentioned that the biscuits served were cold. Resident #50, who had recently arrived at the facility, noted that the food had been cold several times. Staff interviews revealed that the hot plate warmer had not been functional for almost a year, contributing to the issue of serving cold food. An observation confirmed that the temperature of the food items was below the expected levels, with American fried potatoes at 101.9 degrees and BBQ pulled pork at 124.7 degrees. Resident #66, who also had intact cognition, expressed that the food was never hot and often lukewarm, with items missing from her meals. She mentioned not receiving grape juice as listed on her menu. Staff members, including a CNA and a CMA, corroborated the residents' complaints, noting that room trays were more frequently complained about than dining room meals. The facility's policy on food preparation and service, which mandates maintaining proper hot and cold temperatures, was not adhered to, leading to the deficiency.
Inadequate PPE Use and Infection Control Practices
Penalty
Summary
The facility failed to adhere to appropriate infection prevention practices, particularly in the use of Personal Protective Equipment (PPE) for residents requiring Enhanced Barrier Precautions (EBP). Resident #51, who has a dialysis port, reported that staff did not wear gowns during personal care activities such as dressing and bathing. Observations confirmed that staff did not don gowns during these activities, despite the facility's policy requiring gowns for high-contact care activities for residents with indwelling medical devices. The Director of Nursing and the Infection Preventionist acknowledged that PPE, including gowns, should have been used during these interactions. Resident #57, who has a feeding tube, was also subject to inadequate infection control practices. A Registered Nurse entered the resident's room to hook up tube feeding without wearing any PPE, despite being aware of the EBP requirements. This oversight was acknowledged by the nurse after the procedure, indicating a lapse in following the facility's infection control policies. Additionally, Staff Q, an LPN, failed to maintain infection control standards while administering artificial tears to Resident #17. The LPN placed the box of artificial tears on the resident's bed without a barrier and returned it to the medication cart without cleaning it. This action was contrary to the facility's infection control policy, which aims to prevent and manage the transmission of infections. The Director of Nursing confirmed that staff should not place medication on residents' personal items without a barrier.
Failure to Provide Adequate Bathing Opportunities
Penalty
Summary
The facility failed to provide a resident with the opportunity for bathing as per their preference and physician's recommendation. The resident, who had no cognitive impairment, expressed a desire to have baths four times a week, as recommended by their doctor. However, the facility's records and staff interviews revealed inconsistencies in the bathing schedule. The Medication Administration Record indicated a physician's order for showers twice a week, while the Electronic Health Records documented a different schedule of self-bathing three times a week. Despite the resident's request and the physician's recommendation, the records showed that the resident only received showers on four occasions over a month-long period. Interviews with staff, including a CNA and the Director of Nursing (DON), highlighted a lack of communication and awareness regarding the resident's bathing preferences. The CNA mentioned that the resident preferred baths at night, but bath aides were reluctant to accommodate this request. The DON and the Administrator were unaware of the resident's request for more frequent baths, and the facility's policy expected at least two baths per week. This discrepancy between the resident's needs and the facility's actions led to the deficiency in providing adequate care and assistance with activities of daily living, specifically bathing.
Deficiencies in Documentation of Resident Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in documentation. For Resident #21, the facility did not document the presence of hearing aids on the resident's inventory list, despite multiple appointments and interactions regarding the hearing aids. The resident reported a missing hearing aid, which was not documented in the electronic health records (EHR). Staff interviews revealed that the hearing aids should have been documented upon the resident's return from appointments, but there was no policy in place for completing the resident property inventory list. For Resident #231, the facility failed to document an incident in which the resident was lowered to the floor during a transfer due to their leg getting stuck. Although an incident report was created, the event was not recorded in the resident's progress notes in the electronic medical chart. Staff interviews confirmed that the incident should have been documented in the progress notes, indicating a lapse in maintaining accurate medical records.
Failure to Prevent Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent falls for a resident with a history of unsteadiness on feet and repeated falls. The resident, who had no cognitive impairment, experienced three fall incidents within a short period. The incidents occurred on 12/7/24, 12/13/24, and 12/16/24, and were attributed to the lack of proper use of gait belts during transfers. The resident's care plan, which was canceled on 3/10/25, lacked interventions to prevent further falls after the initial incidents. During the incidents, staff failed to use gait belts as required by the facility's policy, which mandates their use to ensure safer handling of residents. The resident's knees buckled during transfers, leading to falls, and the staff had to lower the resident to the floor. The facility's Director of Nursing acknowledged the issue with gait belt usage and noted that the staff was educated on the importance of using gait belts after the incidents. However, the deficiency in supervision and adherence to policy led to repeated falls for the resident.
Failure to Follow Physician's Orders and Document Care
Penalty
Summary
The facility failed to follow physician's orders for a resident who was diagnosed with dementia, urinary tract infection (UTI), depression, autoimmune hepatitis, lymphedema, and pulmonary hypertension. The care plan for this resident included administering antibiotics as ordered and using specific products for incontinence care. However, the antibiotic Cefdinir was not administered as scheduled on the evening of the order date, and the error was only caught two days later. Additionally, the order for using Ivory soap and warm washcloths for incontinence care was not entered into the Treatment Administration Record (TAR) until several days after the order was received. Another resident, who had a history of stroke, anemia, peripheral vascular disease, renal failure, dementia, hemiplegia/hemiparesis, and depression, required oxygen therapy at night and as needed due to Chronic Obstructive Pulmonary Disease (COPD). Despite this, the order for oxygen therapy was not entered into the Medication Administration Record (MAR) or TAR, and there were no supplemental oxygen supplies in the resident's room during observations. The resident was found with low oxygen saturation levels and was not wearing oxygen at the time of a critical incident, leading to hospitalization. The facility's failure to properly document and follow physician's orders for both residents resulted in significant lapses in care. The Assistant Director of Nursing (ADON) acknowledged that orders should be implemented as soon as they are received, and the Regional Nurse Consultant identified an issue with the Electronic Health Record (EHR) system that prevented staff from seeing the oxygen order on the TAR. These deficiencies highlight the need for accurate and timely documentation and adherence to physician's orders to ensure resident safety and well-being.
Inadequate Assistance with Denture and Perineal Care
Penalty
Summary
The facility failed to provide adequate assistance to a resident, identified as Resident #2, in performing activities of daily living, specifically in cleaning her dentures and ensuring proper perineal hygiene. Resident #2, who had a BIMS score of 13 indicating no cognitive impairment, was diagnosed with multiple conditions including stroke, anemia, and dementia. Despite her care plan indicating the need for assistance with oral care and personal hygiene, observations and interviews revealed that her dentures were not cleaned properly, leading to a buildup that was described as mold-like by hospital staff. Additionally, her perineal area was found to be severely excoriated, suggesting inadequate cleansing and care. The deficiency was highlighted when Emergency Medical Services noted a strong smell of urine from Resident #2, indicative of a possible urinary tract infection, upon their arrival at the facility. Hospital staff further observed that her dentures had dark green specks and required extensive cleaning, and her perineal area was severely excoriated, which was not addressed by the facility staff. Interviews with facility staff, including a registered nurse and the Assistant Director of Nursing, revealed a lack of clarity and consistency in the assistance provided to Resident #2, with assumptions made about her independence in oral care and personal hygiene. The facility's policies on denture care and skin assessment were not adequately followed, as evidenced by the condition of Resident #2's dentures and skin. The facility's procedures for denture care and skin assessment emphasize the importance of regular cleaning and monitoring, yet these were not effectively implemented for Resident #2. The failure to adhere to these procedures resulted in significant hygiene issues and discomfort for the resident, as noted by both the hospital staff and the resident's Power of Attorney.
Failure to Resubmit PASRR After Expiration
Penalty
Summary
The facility failed to resubmit the Preadmission Screening and Resident Review (PASRR) for a resident after a 180-day short stay approval expired. The resident, identified as Resident #45, had diagnoses of depression, anxiety disorder, PTSD, bipolar disorder, and homelessness, with a BIMS score indicating no cognitive impairment. The clinical record showed a PASRR Level II Outcome with a short-term approval that expired, but the subsequent PASRR Level I Determination lacked documentation of the resident's active diagnosis of anxiety, ongoing behavioral health services, and homelessness. There was no active PASRR from the expiration date until a later date, and the facility did not have a policy on PASRR. An interview with the Regional Nurse Consultant confirmed that a PASRR was not completed when the short-term approval expired, and the necessary documentation was missing in the subsequent PASRR.
Failure to Document and Follow Physician Orders for Ankle Support Devices
Penalty
Summary
The facility failed to provide professional standards of care by not following physician orders and not entering orders into the electronic health record for a resident. The resident, who had no cognitive impairment, was observed wearing a right foot cam boot while ambulating. The resident reported wearing an additional ankle brace inside the boot but was unsure about the duration and necessity of wearing these devices. The care plan indicated the resident should wear a cam boot per doctor's orders until healed, but there were no specific physician orders documented in the electronic health record regarding the use of the cam boot and ankle brace. Interviews with staff revealed a lack of knowledge about when and how long the resident should wear the cam boot and ankle brace. A CNA stated uncertainty about the resident's use of these devices, and the Director of Nursing confirmed the absence of physician orders related to the resident's boot and ankle brace. The orthopedic consult notes indicated a plan for the resident to use a lace-up ankle brace and wean off the walking boot, but these instructions were not reflected in the facility's records.
Failure to Notify PCP and Delay in Wound Care Treatment
Penalty
Summary
The facility failed to notify the primary care provider (PCP) of a worsening deep tissue injury (DTI) for Resident #16 and delayed initiating wound care treatment for a newly identified DTI for Resident #4. Resident #16, who had a moderate cognitive impairment, was identified with a new skin injury on the left second toe, classified as a DTI. Although staff were instructed to monitor the injury and notify the PCP if it worsened, the injury almost doubled in size by May 23rd without the PCP being informed. The Director of Nursing (DON) and the Regional Nurse Consultant acknowledged the oversight during an interview. Resident #4, with intact cognition and medical diagnoses including anemia and diabetes, returned to the facility with a newly identified DTI on the heel. Despite discussions in a Standards of Care meeting and picture documentation, there were no specific treatment orders for the DTI from April 26th to May 3rd. Treatment was only initiated on May 4th. The Regional Nurse Consultant and the DON confirmed the lack of treatment orders during interviews, acknowledging the delay in care.
Failure to Update Diet Order for Resident
Penalty
Summary
The facility failed to update and liberalize a diet order for a resident with severe cognitive impairment and a stage 2 pressure injury. The resident was initially placed on a regular diet with small portions due to a diabetes diagnosis. However, after a significant weight loss was documented by the Registered Dietitian, it was recommended to discontinue the small portions diet to meet the resident's nutritional needs. This recommendation was discussed in a Standards of Care meeting, but the diet order was not updated as discussed. Consequently, the resident continued on a regular small portion diet, contrary to the recommendations made to prevent further weight loss.
Failure to Follow Prescribed Oxygen Order for Resident
Penalty
Summary
The facility failed to follow the prescribed oxygen order for a resident with medically complex conditions, including chronic kidney disease, heart failure, and respiratory failure. The resident's care plan was updated to include a focus on chronic respiratory failure, with interventions such as administering oxygen as ordered and monitoring for respiratory distress. However, observations showed discrepancies in the oxygen settings, with the resident receiving 4L and 3.5L of oxygen on different days, despite a new order for continuous oxygen at 2L. The previous order for 1-5L as needed was not removed, leading to both orders being listed on the Treatment Administration Record (TAR). The facility's policy on oxygen administration requires staff to verify physician orders and review the resident's care plan for special needs. However, there was no staff documentation indicating a need for oxygen settings above 2L, and the continuous oxygen order was not listed as an intervention on the resident's care plan. Interviews with the Director of Nursing and the Regional Nurse Consultant revealed that the as-needed order should have been removed, and staff were inappropriately directed to include a buffer in oxygen amounts. This oversight resulted in a failure to adhere to the prescribed oxygen therapy for the resident.
Unclean Can Opener Blade in Kitchen
Penalty
Summary
The facility failed to maintain cleanliness of the manual can opener blade in the kitchen, which posed a risk of bacteria growth and cross-contamination. During an initial kitchen tour, the blade was observed to have a blackish color with a small to moderate amount of residue. This condition persisted over two days until the Certified Dietary Manager was informed, and the can opener was cleaned. Despite documented daily cleaning logs indicating the can opener was cleaned, interviews with the Certified Dietary Manager and Registered Dietitian revealed that the cleaning process did not include the blade itself, only the top and sides of the can opener arm. The facility's undated Sanitation policy requires all equipment, food contact surfaces, and utensils to be washed and sanitized thoroughly. For equipment that cannot fit in the dishwashing machine, the policy specifies disassembly and thorough cleaning of all parts. However, the cleaning process for the can opener did not adhere to these guidelines, leading to the observed deficiency.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during care activities for two residents. For Resident #74, who has severe cognitive impairment and requires assistance for mobility, a CNA did not perform hand hygiene after removing soiled gloves and PPE following catheter care. The CNA continued to assist the resident with various tasks, including adjusting bed controls and ambulating the resident, without performing hand hygiene. This was contrary to the facility's hand hygiene policy, which mandates hand hygiene before and after direct contact with residents and after removing PPE. For Resident #21, who is bed-bound with moderately impaired cognitive status and receives nutrition and medication through a PEG tube, an LPN failed to change gloves between repositioning the resident and administering medication. The LPN used the same gloves for both tasks, which is against the facility's Enhanced Barrier Precautions policy. This policy requires changing gloves between high-contact care activities, such as repositioning and device care, to prevent cross-contamination.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that all residents had their call lights within reach, specifically for one resident, identified as Resident #31. Observations on three separate occasions revealed that Resident #31's call light was consistently placed at the end of the bed, out of reach. This was noted on June 3rd, 5th, and 6th, 2024. The facility's policy, revised in March 2021, mandates that call lights should be within easy reach of residents when they are in bed or confined to a chair. An interview with the Regional Nurse Consultant confirmed the expectation that the call light should be accessible to Resident #31, despite the resident's inability to use it.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide a written bed hold notice to a resident and their responsible person after a verbal consent was given for a bed hold during a hospital transfer. Resident #18, who has diagnoses of heart failure, diabetes mellitus, and asthma, and a BIMS score indicating no cognitive impairment, was transferred to the hospital for fluid overload. Upon re-admission, the resident discovered an unexpected bill, indicating a lack of communication regarding the cost of the bed hold. The facility's policy requires that residents or their representatives be informed in writing of the bed-hold and return policy prior to transfers and therapeutic leaves. However, in this case, the Business Office Manager confirmed that no written notice was sent to the resident or their responsible person after the verbal consent was obtained. This oversight was identified during a review of the resident's clinical records and interviews, highlighting a failure to adhere to the facility's established procedures.
Failure to Prevent Accidents and Ensure Safety Measures
Penalty
Summary
The facility failed to ensure the proper use of a mechanical lift, low bed positions, and appropriate footwear and gait belt usage, leading to potential hazards and accidents for three residents. Resident #6, with severe cognitive impairment and dependent on staff for transfers, was observed being transferred using a mechanical lift without the wheelchair brakes being locked, contrary to the operator's instructions. The facility's policy did not include the requirement to lock the wheelchair brakes, which contributed to this oversight. Resident #74, also with severe cognitive impairment and at high risk for falls, was assisted by a CNA from a sitting to a standing position without a gait belt and was ambulated without proper footwear. The resident was wearing socks without non-slip grippers, increasing the risk of falls. The facility lacked a specific policy on the usage of gait belts, which contributed to the improper handling of the resident. Resident #63, with severe cognitive impairment and at risk for falls, experienced an unwitnessed fall from a bed that was in a high position. The bed's height was not investigated, and no interventions were put in place to prevent recurrence. Staff were unsure if the resident could adjust the bed height independently, and the facility's records lacked documentation of an investigation into the bed height or preventive measures. The facility's protocol required identifying interventions to prevent falls, which was not adhered to in this case.
Failure to Follow Physician-Ordered Wound Treatment
Penalty
Summary
The facility failed to provide professional standards of care by not following physician-ordered wound treatment for a resident. The resident, who had a BIMS score of 14 indicating intact cognitive ability, was totally dependent on staff for various activities and had multiple medical conditions including heart failure, chronic kidney disease, and metabolic encephalopathy. The resident's care plan required staff to monitor her legs for skin changes and follow physician orders to prevent further skin impairment. Despite these directives, during an observation, two CNAs discovered an open wound on the resident's ankle that had not been reported to nursing staff. The aides were unsure if nursing was aware of the wound and proceeded to cover it without notifying a nurse immediately. This incident occurred despite a previous skin and wound evaluation noting a blister on the resident's left lateral malleolus, which had been communicated to the provider and covered with a dry dressing for protection. The facility's policy on acute condition changes required that physicians identify and authorize appropriate treatments, and staff monitor and document the resident's progress and response to treatment. However, the failure to report the newly discovered wound to nursing staff and ensure proper follow-up care indicates a lapse in adhering to these professional standards. This deficiency highlights a gap in communication and adherence to care protocols, which are critical for maintaining the health and safety of residents with complex medical needs.
Failure to Reposition Residents According to Care Plans
Penalty
Summary
The facility failed to reposition residents according to their needs for two residents. Resident #2, who had a history of stroke, was nonverbal, and required assistance for bed mobility, was observed multiple times lying on her back despite an order to be positioned on her side. This resident had a pressure ulcer and was at risk for further skin breakdown. Observations on different days showed that the resident remained on her back for extended periods, contrary to the care plan and medical orders. An agency RN confirmed that the resident should have position changes every two hours, which was not adhered to by the staff. Resident #15, who was severely impaired in cognitive skills and dependent on staff for daily activities, was frequently observed sleeping in her wheelchair with her head hanging down. Despite the care plan directing staff to lay the resident down after meals if she was sleeping and to assist with weight shifting every two hours, the resident was left in the wheelchair for extended periods without repositioning. Observations over several days showed that the resident remained in the wheelchair for hours, indicating a failure to follow the care plan and facility policy on repositioning to prevent skin breakdown.
Inadequate Infection Control Measures
Penalty
Summary
The facility failed to use adequate infection control measures for two residents, leading to potential risks of pathogen spread. Resident #5, who had an intact cognitive ability and was totally dependent on staff for various activities, was observed with a urinary catheter bag containing over 1000 cc of urine. A CNA, without wearing gloves or a gown, unhooked the catheter bag, emptied it into a container that overflowed, and then wiped the urine off the floor with a paper towel. The CNA then reattached the catheter bag without using gloves, violating infection control protocols. Resident #5 had multiple diagnoses, including neurogenic bladder, diabetes mellitus, and chronic wounds, making her highly susceptible to infections. The care plan indicated the need for enhanced barrier precautions, which were not followed during the observed incident. Resident #24, who also had an intact cognitive ability and was totally dependent on staff for toileting and other activities, was observed receiving incontinence care from two CNAs. During the care, one CNA's long hair fell onto the protective padding on the resident's bed, and she repeatedly flung her hair to the side, causing it to fall back onto the bed. After completing the care, the CNA removed her gown, allowing her hair to flow over the front of the gown, and left the room without washing her hands. The other CNA also left the room with trash in her hand, stating she would wash her hands later, and touched door handles with a gloved hand. Resident #24 had conditions including MASD, heart failure, and chronic kidney disease, and was at risk for infection due to an indwelling catheter. The care plan required enhanced barrier precautions, which were not adhered to during the observed care.
Deficiency in Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
The report highlights a concerning deficiency in the nursing home's implementation of interventions to prevent falls and injuries, particularly for Resident #6. Resident #6, identified with moderately impaired cognitive skills and a history of repeated falls, experienced multiple incidents resulting in injuries, including a fracture of the posterior 8th rib and a right hip fracture. Despite the resident's documented predisposing factors for falls, such as confusion and impaired memory, the facility's interventions appeared inadequate in addressing Resident #6's specific risks and needs to prevent further incidents. Incident reports detailed instances where Resident #6 fell multiple times within a short period, with observations of pain, bruises, and fractures. The facility's care plan revisions included educational interventions aimed at reminding Resident #6 to seek assistance and use the call light, but the ongoing pattern of falls and injuries suggests a gap in the effectiveness of these measures. Additionally, staff interviews revealed discrepancies in acknowledging Resident #6's cognitive status, with conflicting accounts of confusion and ability to follow directions, raising questions about the consistency and accuracy of assessments and care planning. The facility's Falls and Fall Risk Management policy outlined comprehensive approaches to identifying and addressing fall risk factors, including environmental, resident-related, and medical factors. However, the report indicates a failure to effectively implement these strategies for Resident #6, leading to a series of preventable incidents resulting in injuries. The lack of timely and tailored interventions tailored to the resident's cognitive status and history of falls contributed to the ongoing safety concerns and deficiencies in supervision and accident hazard prevention within the nursing home area.
Failure to Answer Call Lights Timely
Penalty
Summary
The facility failed to consistently answer call lights within a reasonable amount of time, defined as 15 minutes or less, for six residents. Resident #20 reported turning on the call light at 6:15 PM and not receiving assistance until 7:00 PM, when her daughter intervened. Resident #21 was left on the toilet from 5:00 AM to 9:30 AM because the staff member needed assistance from another person. Resident #18 also expressed concerns about call light response times. Staff AA reported that another staff member failed to assist a resident after the call light had been on for 20 minutes and left without giving a report. Resident #17 turned on her call light at 6:00 AM and did not receive help until 8:00 AM, despite making multiple calls to the facility. Resident #22 reported waiting at least 30 minutes each evening, with one instance of waiting 1.5 hours for assistance. Staff BB, an LPN, confirmed that call lights are not answered within 15 minutes during weekend shifts due to short staffing, sometimes taking up to 45 minutes to respond. The facility's procedure for answering call lights, revised in 2021, aims to ensure timely responses to residents' requests and needs. However, the Director of Nursing (DON) reported that staff are expected to answer call lights within 15 minutes, which was not consistently happening. The report highlights multiple instances where residents experienced significant delays in receiving assistance, indicating a failure to meet the facility's own guidelines and expectations for timely response to call lights.
Failure to Sustain Effective QAPI Program
Penalty
Summary
The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program, which is essential for providing quality care to residents. The Iowa Department of Inspections, Appeals, and Licensing (IDIAL) identified multiple violations during their recertification visits on 3/30/23 and 10/24/23. These violations included issues related to resident rights, professional standards of services, activities of daily living (ADL) care, quality of care, accident hazards, respiratory care, sufficient nursing staff, nutritional value of food, frequency of meals, food procurement and sanitation, and resident records. The repeated nature of these violations indicates a systemic problem in the facility's ability to maintain and improve care standards through their QAPI program. The facility's QAPI program, as outlined in their policy, is overseen by a committee that includes the Administrator, Director of Nursing Services, Medical Director, and representatives from various departments. Despite this structure, the facility has not effectively addressed the identified deficiencies. The Director of Nursing (DON) reported that plans of correction (POC) are followed and completed weekly, with audits conducted daily or weekly. However, the repeated violations suggest that the interventions and reassessments made by the QAPI team were insufficient to resolve the underlying issues. The facility's failure to implement and maintain an effective QAPI program has resulted in ongoing deficiencies that impact the quality of care provided to residents.
Infection Control and Food Handling Deficiencies
Penalty
Summary
The facility failed to complete proper hand hygiene while providing incontinence care for two residents. During the observation, staff members did not change gloves or perform hand hygiene at appropriate times, such as after touching potentially contaminated surfaces and before handling clean items. For instance, one staff member handled a package of wipes, moved the bed, and accessed the closet without changing gloves or performing hand hygiene before assisting with perineal care. Another staff member placed wipes directly on the bed and continued to use them without changing gloves or performing hand hygiene. The Director of Nursing confirmed that staff should not wear soiled gloves prior to assisting residents with care, and the facility's hand hygiene policy emphasized the importance of hand hygiene in preventing infections. Additionally, the facility failed to pass food in a sanitary manner. Observations revealed that staff members handled ready-to-eat food items with their bare hands instead of using utensils. For example, a cook picked up pieces of bread with bare hands and served them to residents, and a CNA placed packets of margarine directly on food items with bare hands. The Corporate Dietitian confirmed that staff should use utensils to handle food and avoid placing margarine packets directly on ready-to-eat food. The facility did not provide a policy on dietary sanitation services.
Failure to Respect Resident Dignity and Rights
Penalty
Summary
The facility failed to respect the dignity of Resident #2, who had moderately impaired cognition and required maximal assistance for transfers and toilet hygiene. Staff Q, a CNA, reported overhearing Staff T, an LPN, yelling at Resident #2, which was corroborated by other staff members who also heard the yelling. Resident #2 expressed feeling bad for needing help and felt that the nurse was tired of her, indicating a lack of respectful communication and care from the staff. The facility's Dignity policy mandates that residents be treated with respect at all times, which was not adhered to in this case. The facility also failed to provide privacy during perineal care for Resident #14. During an observation, Staff I and Staff J assisted Resident #14 with perineal care while the privacy curtain was left open approximately 15 inches. Resident #14 mentioned that she did not notice the curtain being open and that it happened frequently, indicating a systemic issue with maintaining resident privacy. The facility's Resident Rights policy guarantees the right to privacy, which was violated in this instance. Additionally, the facility did not honor Resident #15's request to bathe three times a week, despite having a physician's order for it. Resident #15 reported filing a grievance and being told that the order had expired, although her physician clarified that such orders do not expire. The facility's Grievance binder and medical chart confirmed the resident's request and the physician's order, yet the facility failed to comply. This failure to respect the resident's care preferences and physician's orders is a violation of the Resident Rights policy, which ensures residents can exercise their rights without interference.
Failure to Notify Physician of Resident's Supplement Refusals
Penalty
Summary
The facility failed to notify the physician that a resident continued to refuse supplements, resulting in continued weight loss. The resident, who had no cognitive impairment and was diagnosed with cancer and anemia, experienced significant weight loss since admission. Despite the facility's initial notification to the primary care provider and the subsequent orders for juice and house supplements, the resident frequently refused these supplements. The clinical records lacked documentation of physician notification regarding these refusals, and the care plan did not include information about the use of nutrition supplements. The resident's weight continued to decline over several months, with significant weight loss documented at various intervals. The facility's records showed multiple instances where the resident refused the prescribed supplements, but there was no evidence that the physician was informed of these refusals. The Director of Nursing confirmed that the nurse should notify the physician if a supplement did not work for a resident. The facility did not provide a policy on the notification of physicians regarding changes in the resident's condition.
Failure to Ensure Grievance Policy Compliance
Penalty
Summary
The facility failed to ensure that residents and their families could file grievances without fear of reprisal and did not follow up on all grievances. A former resident's family member reported that she had filed a grievance in November 2023 regarding her mother not receiving a scheduled bath. She expressed concerns about staff potentially removing the grievance from the box and noted that the facility never followed up on this particular grievance, although they had followed up on others she had filed previously. The grievance binder lacked any record of the grievance about the bath. The facility's policy, revised in April 2017, states that residents and their representatives have the right to file grievances without fear of discrimination or reprisal and that all grievances should be maintained on file for a minimum of three years. However, the facility did not adhere to this policy in this instance. The Regional Director of Clinical Services questioned why the family member did not call the office to follow up on the grievance, indicating a lack of proactive follow-up from the facility's side.
Failure to Update PASRR for Resident with Behavioral Changes
Penalty
Summary
The facility failed to refer a resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR) to the appropriate state-designated authority for a Level II PASRR evaluation and determination. The resident, identified with severe cognitive impairment and diagnosed with Parkinson's Disease and repeated falls, exhibited significant behavioral changes, including agitation, combativeness, and refusal to follow instructions. Despite these behaviors and the administration of multiple psychiatric medications, the facility did not update the PASRR or include specific behavioral interventions in the care plan. Behavior notes indicated that the resident became more agitated and combative on several occasions, leading to the administration of Haldol and other psychiatric medications. The clinical records showed multiple instances of medication adjustments without a corresponding update to the PASRR. The Director of Nursing confirmed that a new PASRR should have been completed for the resident, and the facility lacked a policy on PASRR submissions.
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An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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