Winslow House Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Marion, Iowa.
- Location
- 3456 Indian Creek Road, Marion, Iowa 52302
- CMS Provider Number
- 165440
- Inspections on file
- 26
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Winslow House Care Center during CMS and state inspections, most recent first.
A resident who required substantial/maximal assistance for transfers and was identified as a fall risk was being moved from bed to a shower chair using a full body mechanical lift operated by two CNAs. After the sling was raised, the CNA operating the lift activated the leg-spreading function, assumed the legs were fully opened based on the usual grinding noise, and then backed and turned the lift. Because the lift legs were not fully spread, the lift became imbalanced, tipped to one side, and the wheels lifted off the floor, causing the resident to be lowered to the ground while still attached to the lift. The lift’s crossbar struck the resident’s eyebrow, resulting in a bruise, and the resident also sustained a small skin tear on the toe, as documented by nursing staff.
The facility failed to maintain an effective QAPI process to identify and correct a previously cited infection control deficiency. A prior survey had found that staff did not use Enhanced Barrier Precautions during care for at-risk residents, and a later complaint and incident survey again cited the same issue under F880. The Administrator reported that she monitors and audits QAPI effectiveness and confirmed the ongoing concern about the repeated infection control deficiency, with 47 residents in the facility at the time.
A resident with multiple comorbidities, severe cognitive impairment, and a Stage III pressure ulcer on the left lateral foot had a physician order for daily evening-shift wound care, including cleansing, betadine application, and foam dressing with gauze wrap. After a visit to a wound provider, the resident’s wound dressing remained dated from that appointment, and the resident reported that wound care had not been done for at least one night. A PT note and incident report documented that the dressing had not been changed as ordered, while an LPN had signed the treatment record indicating wound care was completed on several days, later admitting he had not performed the dressing change and had signed it off because the wound clinic had changed the dressing. An RN subsequently confirmed the outdated dressing and completed the overdue treatment, revealing a failure to provide and accurately document wound care as ordered.
A resident with multiple comorbidities, severe cognitive impairment, and a stage 3 pressure ulcer had a care plan requiring Enhanced Barrier Precautions (EBP), including gown and glove use for high-contact care, PPE availability at the room entrance, and door signage indicating required precautions. During an observed wound dressing change, an RN performed the entire procedure without donning a gown, and the room lacked both PPE signage and available PPE. The RN later stated she forgot to wear the gown and noted the absence of signage after the resident’s recent room change, despite facility policy directing gown and glove use for wound care under EBP.
Staff failed to consistently document the administration and inventory of controlled medications, resulting in discrepancies between medication counts, delivery records, and the Medication Administration Record. In several cases, staff administered narcotics without immediate documentation, and incomplete records prevented accurate tracking of controlled substances for multiple residents with pain management needs.
The facility failed to update care plans for two residents, one with schizophrenia and another with hearing impairment. The care plan for the resident with schizophrenia lacked goals and interventions related to the diagnosis, while the resident with hearing impairment reported inadequate staff accommodation for her needs. Staff interviews revealed unclear responsibilities for updating care plans.
A resident requiring gastric tube medication administration experienced deficiencies in care when medications were given late without physician notification, an extended-release tablet was crushed, and Enhanced Barrier Precautions were not followed. The RN failed to wear a protective gown during the process, contrary to facility policy.
Improper Mechanical Lift Use Leads to Resident Fall and Minor Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of a full body mechanical lift during a bed-to-chair transfer, resulting in a fall with injury for one resident. The resident had no cognitive impairment, required substantial/maximal assistance for transfers, and had diagnoses including heart failure, diabetes, and a left heel pressure ulcer. The resident was care planned as a fall risk, with directions for staff to use a full body lift with two staff for transfers to a shower chair. On the day of the incident, two CNAs used a brand-name full body mechanical lift to transfer the resident from bed to a shower chair. During the transfer, staff reported that after raising the resident in the sling, the CNA operating the lift pressed the control to separate the lift’s legs and heard the usual grinding noise, then assumed the legs had fully opened. She then backed the lift away from the bed and began to turn it toward the shower chair. As the lift was turned, it began to lean to one side, and the wheels lifted from the floor. Staff accounts and subsequent checks indicated that the legs of the lift had not been fully opened, causing imbalance and tipping of the lift while the resident was suspended. As the lift tipped, one CNA attempted to hold the lift and another attempted to support and lower the resident. The lift’s crossbar struck the resident’s eyebrow, causing a bruise measuring 2.5 cm by 1 cm, and the resident also sustained a skin tear on the lateral side of the right great toe measuring 1 cm by 0.5 cm. The resident was found on the floor on her back with knees bent, still attached to the lift, which was on its side. The resident reported that the machine tipped over while staff were transferring her. Staff and nursing assessments documented the bruise to the forehead and the skin tear to the toe, which healed within a few days, and the resident denied pain, headache, or nausea following the incident.
Repeated Infection Control Deficiency Due to Ineffective QAPI Process
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Quality Assurance Performance Improvement (QAPI) process to identify and correct a previously cited infection control problem. A prior CMS 2567 dated 9/25/2025 documented a deficiency for staff failure to use Enhanced Barrier Precautions during resident care for residents identified as at risk. During a subsequent complaint and facility-reported incident survey on 1/28/2026, surveyors again identified the same infection control deficiency under F880, indicating that staff continued not to use Enhanced Barrier Precautions as required for at-risk residents. In an interview on 1/28/2026, the Administrator stated that she monitors and audits the effectiveness of the QAPI process and acknowledged the concern about the repeated pattern of the F880 deficiency. The facility had a reported census of 47 residents at the time of the current survey.
Failure to Complete and Accurately Document Ordered Wound Care Treatment
Penalty
Summary
The deficiency involves the facility’s failure to complete ordered wound treatment for a resident with a documented Stage III pressure ulcer on the left lateral foot. The resident’s MDS showed diagnoses including heart failure, diabetes, non-Alzheimer’s dementia, vascular disease, and a Stage III pressure ulcer, with severe cognitive impairment (BIMS score 5/15) and a need for staff assistance with ADLs. The care plan directed staff to assess the pressure ulcer and surrounding skin weekly and to complete treatments as ordered. A physician order dated 11/17/25 specified that staff were to cleanse the foot wound and surrounding skin, paint the callous and wound with betadine, cover with a foam dressing, and secure with gauze wrap and tape, to be completed daily on the evening shift. On 12/16/25, the resident attended a local wound provider appointment and returned without new orders. A progress note from the wound provider on that date documented that the wound appeared worse, with increased dimensions, and described the diabetic left lateral wound as clean, painful, and fragile, present for more than a year. On 12/18/25, a physical therapy treatment note documented that the resident stated wound care had not been completed the previous night and that the wound cover was still dated 12/16 from the wound doctor appointment; the Administrator was notified. An incident report from the same date recorded that the Administrator was informed that the dressing on the resident’s left foot had a past date and had not been changed on the evening shift, and that when the day nurse went to change the dressing, the resident reported that no one had changed the dressing for a couple of days. Review of the December 2025 treatment record showed that an LPN (Staff K) had signed off the wound treatment as completed on 12/15, 12/16, and 12/17, placing his initials with a check mark indicating completion. In a subsequent interview, Staff K admitted he forgot to do the dressing change on the day the resident went to the wound clinic, could not recall the exact date, and stated he had just signed it off because the wound clinic had done the dressing change that day. He further stated that he did not make any progress notes regarding the wound and reported that everyone else did it that way on days a resident went to the wound clinic. The DON and ADON reported becoming aware of the issue when the resident was found on 12/18/25 with a dressing dated 12/16/25, and an RN confirmed observing the dressing dated 12/16 and completing the scheduled dressing change on her shift because it had apparently not been done as ordered on 12/17. The facility’s medication administration policy required staff to administer medications as prescribed and to sign the medication administration record after administration, underscoring that documentation should reflect actual completion of ordered treatments.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not utilizing Enhanced Barrier Precautions (EBP) for a resident requiring wound care. The resident had diagnoses including heart failure, diabetes, non-Alzheimer’s dementia, vascular disease, and a stage 3 pressure ulcer, and required substantial assistance with toileting and bathing and partial assistance with ambulation. The MDS showed a BIMS score of 5/15, indicating severe cognitive impairment. The resident’s care plan, dated 9/8/25, specified the need for EBP due to a wound, with goals to reduce the spread of infectious agents and minimize transmission of infection. Interventions directed staff to wear a gown and gloves for high-contact activities, keep PPE available near the room entrance, maintain signage on the door indicating required precautions and PPE, and practice good hand hygiene. On observation, the resident’s bedroom door lacked PPE signage and the room did not have PPE available for staff use. A RN entered the room to perform a daily dressing change and, contrary to the EBP requirements and facility policy, did not don a disposable gown while assembling supplies, elevating the resident’s foot, removing a soiled dressing with a dark substance, measuring the wound, performing the wound treatment, and re-dressing the wound. The RN acknowledged in interview that she did not wear a gown as required and attributed this to forgetting, noting the absence of a sign on the door and that the resident had recently changed rooms. The Assistant DON later stated that the resident had recently changed rooms and that staff must not have brought the sign and PPE to the new room. Review of the facility’s Transmission Based Precautions policy, updated 4/1/24, confirmed that EBP requires staff to don gowns and gloves prior to high-contact care activities such as wound care for any skin opening requiring a dressing.
Failure to Accurately Account for and Document Controlled Medications
Penalty
Summary
The facility failed to maintain an accurate inventory and proper documentation of controlled medications for multiple residents. For several residents with significant pain management needs and complex medical histories, staff did not consistently document the administration of controlled substances on the Medication Administration Record (MAR) or the Controlled Substance Shift Count and Usage Record. In several instances, staff signed out medications on the count sheet but failed to record the administration on the MAR, and in some cases, the facility could not provide complete records for medication deliveries and usage. There were also discrepancies between the number of doses delivered, the number remaining, and the documentation provided. Observations revealed that staff did not always sign out narcotics at the time of administration, leading to inconsistencies between the physical count of medications and the documented records. For example, empty medication packs were found when records indicated doses should remain, and staff admitted to administering medications without immediately documenting them. In one case, a medication cassette was found to contain a Tylenol tablet instead of the prescribed controlled substance, and the facility's investigation confirmed the discrepancy. Staff interviews confirmed lapses in documentation and adherence to procedures for handling and recording controlled substances. The facility's policies required immediate documentation of controlled substance administration and mandated that two staff members verify and sign off on narcotic counts at shift changes. However, these procedures were not consistently followed, as evidenced by incomplete records, missing documentation, and staff admissions of failing to sign out medications as required. These failures resulted in an inability to accurately account for controlled medications received, dispensed, and administered to residents.
Care Plan Deficiencies for Residents with Schizophrenia and Hearing Impairment
Penalty
Summary
The facility failed to ensure comprehensive care plans were reviewed and revised in a timely manner for two residents. Resident #27, diagnosed with schizophrenia, had a care plan that lacked goals, triggers, and interventions related to this diagnosis. Despite the resident's confirmation of having schizophrenia for a long time, the care plan only included focus areas for Asperger's Syndrome, schizoid personality disorder, and depression. The resident's progress notes did not document the new diagnosis or any communication with the provider or discussion with the resident for care planning. Staff interviews revealed a lack of clarity on responsibility for updating care plans, with the MDS Nurse Coordinator relying on information from the Director of Nursing. Resident #25, diagnosed with Meniere's disease and unspecified hearing loss, reported that staff did not accommodate her hearing needs adequately. The care plan included an intervention to ensure the resident's glasses were in good repair but lacked documentation related to her hearing, hearing aid care, goals, or interventions. The resident expressed dissatisfaction with the staff's communication regarding her hearing needs. A nurse consultant acknowledged the need for care plans to be reviewed and updated to reflect the residents' needs.
Medication Administration and EBP Failures
Penalty
Summary
The facility failed to adhere to professional standards of medication administration for a resident requiring medications via gastric tube. The resident, who was on NPO status and required tube feeding, had medications scheduled for 8:00 AM. However, these medications were administered late, and the physician was not notified of the delay as required by the facility's policy. Additionally, an extended-release tablet was crushed, which is against standard medical practice, and this error was not questioned or clarified with the physician. During the medication administration process, the registered nurse did not follow Enhanced Barrier Precautions (EBP) as she failed to wear a protective gown, despite being aware of the requirement. This oversight was acknowledged by the nurse and confirmed by the facility's Director of Nursing and Administrator designee. The facility's policy and training materials clearly outlined the necessity of wearing a gown and gloves when caring for residents with gastric tubes, which was not adhered to in this instance.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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