Accura Healthcare Of Ames, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Ames, Iowa.
- Location
- 3440 Grand Avenue, Ames, Iowa 50010
- CMS Provider Number
- 165423
- Inspections on file
- 26
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Accura Healthcare Of Ames, Llc during CMS and state inspections, most recent first.
Missing Written Bed Hold Notification Before Hospital Transfers: The facility failed to provide written bed hold information to two residents or their representatives before hospital transfers. One resident had severe cognitive impairment, respiratory failure, and ESRD on dialysis and was sent from the dialysis center for low O2 saturation; the other had intact cognition, osteomyelitis, and muscle weakness and was transferred for a hip fracture. Records lacked documentation of bed hold notification for either transfer, and the Administrator could not locate the required information.
Inaccurate MDS coding affected three residents. One resident’s MDS incorrectly indicated no serious mental illness/IDD despite a positive PASRR screen and diagnoses of anxiety, depression, and bipolar disorder. Two other residents’ MDSs lacked diabetes diagnoses but still coded weekly Zepbound injections as insulin use, even though both residents said the medication was for weight loss. The MDS Coordinator said she relied on the PASRR evaluation and EMAR, and the DON stated she was unsure whether Zepbound should be coded as insulin.
The facility failed to develop and implement complete care plans for two residents. One resident smoked multiple times a day, but the care plan did not include smoking behaviors or the supervision needed while smoking, even though the resident was observed smoking in the designated courtyard with staff present. Another resident with moderately impaired cognition had a care plan directing staff to keep the bed low and use a fall mat, but staff found the resident on the floor with the arm pinned between the mattress and side rail after the bed was not low and the fall mat was not in place.
Failure to Perform Hand Hygiene and Change Gloves During Resident Care: Staff CNAs provided toileting and transfer care to a resident with no cognitive impairment and diagnoses of diabetes and depression, but did not perform hand hygiene after removing contaminated gloves, before touching clean surfaces, or when moving from dirty to clean tasks. One CNA also changed gloves without hand hygiene after cleansing stool from the resident and then continued care, while the other CNA touched the sling, clothing, and a window after glove removal without cleaning hands.
A resident with newly identified mental health diagnoses and related medication orders did not receive a timely Level II PASRR evaluation. The facility lacked a specific protocol for submitting PASRRs, resulting in a delay in the required screening process after the resident's mental health status changed.
A resident with physical dependencies and a history of muscular dystrophy, PTSD, and burns was allowed to use and store a vape pen in his room without proper assessment or supervision. Staff were inconsistently aware of the resident's vaping, and the required smoking evaluation and care plan were not completed, contrary to facility policy prohibiting smoking or vaping inside and mandating secure storage of such materials.
Three residents with indwelling urinary catheters were observed with catheter tubing in contact with the floor or other unclean surfaces, despite care plans directing proper catheter maintenance and monitoring. Staff and leadership acknowledged lapses in following protocol and the absence of a specific catheter care policy, while residents experienced complications including UTIs and required medical intervention.
Surveyors found that food items in the kitchen were left uncovered and lacked proper labeling and dating, including drinks, salads, and unidentified meat. Staff also brought in items that were not labeled or dated, and the ice scoop was stored unsanitarily on top of the ice machine instead of in a container, contrary to facility policy.
The facility submitted inaccurate staffing data to CMS by misclassifying staff roles in the PBJ system, including CNAs coded as CMAs and administrative staff coded as direct care staff. These errors occurred on multiple occasions, leading to incorrect reporting of staffing levels, especially on weekends. Leadership interviews confirmed expectations for accurate clock-ins and schedule matching, but discrepancies persisted despite established review processes.
A facility failed to provide adequate supervision, resulting in injuries to two residents. One resident, requiring assistance with personal hygiene, was left unattended in the bathroom and fell, sustaining a hip fracture. Another resident, with severe cognitive impairment, was sent to a dental appointment without staff accompaniment, fell, and suffered a dental fracture. Both incidents highlight a lack of adherence to care plans and supervision protocols.
The facility failed to provide adequate supervision during medication administration for three residents. A resident with mild cognitive impairment was left unattended with medications, while another resident's medical information was left visible on a computer screen. Additionally, a glass of water containing medication was left unsupervised at a dining table. The Director of Nursing acknowledged the lack of a specific policy on leaving medications unattended.
The facility failed to maintain safe and appetizing temperatures for food served to residents. A cook checked the temperature of 13 menu items, all above 135°F, but the first tray on the delivery cart had broccoli at 99.0°F, tater tots at 127.9°F, and milk at 44.7°F. Remaining food on the steam table was also below the required temperature. The facility's policy required hot foods to be at least 135°F and cold foods below 41°F. The administrator acknowledged the need to discard the food and prepare a new plate.
The facility failed to maintain sanitary practices in food storage and preparation, with undated and unlabeled food items found in refrigerators and freezers. Staff members were observed not using required hairnets and beard coverings in the food preparation area, violating the facility's policies on food safety and sanitation.
A facility failed to refer a resident for a Level II PASARR evaluation despite the resident's diagnosed serious mental disorder and use of psychotropic medications. The resident had moderate cognitive impairment and was diagnosed with various mental health conditions, including personality disorders and PTSD. The facility did not update the PASARR after new diagnoses were added, and lacked a policy for regular PASARR audits.
A facility failed to maintain a safe environment by leaving a medication cart unlocked and unsupervised. A CMA left the cart unattended while administering medications to a resident, with the cart positioned out of sight. The DON acknowledged the lack of a policy requiring staff to lock medication carts when not in sight, expecting adherence to professional standards.
The facility failed to provide the correct protein portion size for three residents on pureed diets. Staff A prepared a pureed mixture and served only one #8 scoop of protein instead of the required two, resulting in half the necessary portion size being served. The Administrator confirmed that staff should follow the pureed conversion chart, which was not adhered to during meal service.
The facility failed to maintain proper infection control practices in two incidents. A CMA prepared medication for a resident without performing hand hygiene after coughing and blowing her nose. Additionally, a cook placed a resident's blanket in a shared sink, compromising sanitation. The resident had severely impaired vision and required assistance with personal hygiene. The DON confirmed these actions were against the facility's guidelines.
The facility failed to maintain confidentiality during medication administration for two residents. A CMA left a glass of water with Miralax unattended at a dining table, and an RN did not secure a computer screen displaying a resident's information. The DON acknowledged the lack of a policy for securing computer screens.
Missing Written Bed Hold Notification Before Hospital Transfers
Penalty
Summary
The facility failed to ensure that written bed hold information was provided to the resident or representative before transfer to the hospital for 2 of 2 residents reviewed for hospitalization. Resident #3 had a BIMS score of 4, indicating severe cognitive impairment, and diagnoses that included respiratory failure and end stage renal disease with dialysis. Progress notes showed the resident was transferred from the dialysis center to the hospital for low oxygen saturation, and the clinical census documented a hospitalization from 12/24/25 to 12/29/25, but the record lacked documentation of bed hold notification before that transfer. Resident #69 had a BIMS score of 13, indicating intact cognition, and diagnoses that included osteomyelitis and muscle weakness. Progress notes showed the resident was transferred and admitted to the hospital due to a hip fracture, and the clinical census documented hospitalization with billing stopped on 1/20/26, but the record lacked documentation of bed hold notification before the 1/18/26 hospitalization. The facility policy titled Emergency Notice of Transfer/Discharge stated that federal regulations require written notice regarding transfer to the hospital and appeal rights, and the Administrator stated during interviews that he could not locate bed hold notification information for either resident and would have expected such notifications to be present.
Inaccurate MDS Coding for PASRR Status and Insulin Use
Penalty
Summary
The facility failed to accurately complete MDS assessments for 3 of 20 residents reviewed. For one resident, the MDS indicated no serious mental illness and/or intellectual disability or related condition even though the assessment included diagnoses of anxiety, depression, and bipolar disorder, and a PASRR Level I screen dated 11/17/25 showed a positive screening with no status change and directed the facility to mark yes for MDS question A1500. For two other residents, the MDSs lacked a diagnosis of diabetes mellitus but each assessment reflected insulin use 1 of 7 days during the lookback period, while the physician orders showed weekly Zepbound injections for weight management. One resident denied being diabetic and stated he took a weekly shot for weight loss, and the other resident denied being diabetic and thought she took a weekly injection for weight loss. The MDS Coordinator stated she gathered information by observing on the floor and talking to residents, used the last PASRR evaluation to answer A1500, and used the EMAR to code insulin injections in the last 7 days. She stated she had several residents getting Wegovy and marked them as 1 day of insulin because she counted them as insulin, and said she would submit an MDS correction if that was incorrect. The DON stated she did not know if Zepbound should be coded as insulin on the MDS and confirmed both residents took it for weight loss. The FDA information in the report identified Zepbound as a GIP and GLP-1 receptor agonist used for chronic weight management, and the LTC Facility Resident Assessment Instrument 3.0 User's Manual defined insulin as a medication used to treat diabetes mellitus and directed staff to code high-risk drug class medications according to pharmacological classification, not how they are being used.
Incomplete Care Plans for Smoking Supervision and Fall Prevention
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that accurately reflected resident needs and safety interventions for two sampled residents. Resident #17’s admission MDS documented that they did not use tobacco, but later smoking evaluations dated 1/13/26 and 4/12/26 documented that the resident smoked multiple times throughout the day and night. The facility’s smoking information identified the 400 Hall Courtyard as the smoking area, and the resident was observed smoking there on 4/15/26 and 4/16/26 with staff present. However, the resident’s care plan, initiated 1/16/26, did not include documentation related to smoking or the supervision needed for the activity, despite the facility’s smoking policy requiring smoking measures to be documented on the care plan and communicated to staff responsible for supervision. Resident #72 had a BIMS score of 11 on the MDS, indicating moderately impaired cognition. The resident’s care plan, revised on 4/15/25, directed staff to keep the bed in the low position and ensure a fall mat remained in place. On 7/1/25, the resident was found on the floor with the left arm pinned between the mattress and side rail, and the incident report documented that staff failed to place the bed in the low position and failed to put the fall mat in place as required. The review of the care plan interventions and effectiveness noted that the care chart did not have the fall mat intervention even though it was listed on the care plan.
Failure to Perform Hand Hygiene and Change Gloves During Resident Care
Penalty
Summary
The facility failed to maintain infection control practices for 1 of 3 residents reviewed, Resident #26, by not completing hand hygiene and changing gloves during resident care. Resident #26’s MDS assessment dated [DATE] showed a BIMS score of 15, indicating no cognitive impairment, and identified that the resident depended on staff for toilet hygiene and transfers. The resident also had diagnoses of diabetes and depression. On 4/13/26 at 3:05 PM, Staff G and Staff H, both CNAs, entered Resident #26’s room, applied gloves, and transferred the resident with a stand-up lift from a wheelchair to a commode. Staff H lowered the resident’s pants before reaching the commode. After leaving the room, both staff removed their gloves but did not perform hand hygiene; Staff G went to the nurse’s station and Staff H picked up a lift sling and walked down the hall. Later that day at 3:35 PM, Staff G and Staff H returned to the room. Staff H applied gloves and cleansed between the resident’s buttocks where stool was present, then removed the gloves and put on new gloves without hand hygiene before pulling up the resident’s pull-up and pants. Staff G and Staff H then transferred the resident back to the wheelchair, and Staff G removed gloves and touched the sling, clothing, and opened the window without hand hygiene. The facility’s Hand Hygiene policy, updated 11/13/24, required hand hygiene before donning gloves, after removing gloves, and after handling contaminated items. The DON stated she expected staff to complete hand hygiene immediately after removing gloves and after completing cares, and when going from a dirty task to a clean task.
Failure to Submit Timely Level II PASRR Evaluation for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who developed new mental health diagnoses after admission. Clinical record review showed that the resident had multiple mental health diagnoses, including delusional disorder, adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, and depression, with corresponding medication orders for antipsychotic, antianxiety, and antidepressant medications. The resident's care plan identified behavioral concerns and interventions related to impulsivity and excessive use of the call light. Despite these new diagnoses and medication changes, the facility did not initiate a Level II PASRR evaluation until several months after the resident's mental health conditions were documented. The initial PASRR Level I screen indicated no mental health diagnosis at admission, with instructions to submit a new screening if changes occurred. Staff interviews confirmed that there was no specific policy or protocol in place for timely completion of PASRRs, and the process for the Level II evaluation only began after the deficiency was identified.
Failure to Assess and Supervise Resident Vaping in Room
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not properly assessing and supervising a resident who used a vape pen in his room. The resident, who had intact cognition but was dependent on staff for bathing, toileting, and transfers, and used a wheelchair for mobility, was not included on the facility's list of smokers and did not have a completed smoking evaluation in his clinical record. Despite signing an admission checklist indicating receipt and understanding of the facility's smoking policy, the resident reported using a vape pen in his room, keeping it on his person, and charging it himself. He stated he was unaware that vaping in his room was prohibited and was unsure if staff knew about his vaping habits. Staff interviews revealed inconsistent awareness and enforcement of the facility's smoking policy. A CNA stated that residents were required to vape outside with supervision and could not keep vaping supplies in their rooms, but was unaware that the resident vaped. An RN had seen the vape pen in the resident's room and assumed he vaped there, but did not report this to administration. The administrator was unaware of the resident's vaping and stated that staff were expected to report such incidents. The facility's smoking policy explicitly prohibited smoking or vaping inside the facility, required storage of all smoking materials by staff, and mandated smoking evaluations and care plan interventions for residents who smoke or vape. These procedures were not followed for the resident in question, resulting in a failure to prevent potential accident hazards.
Failure to Prevent Catheter-Associated UTIs Due to Improper Catheter Care
Penalty
Summary
The facility failed to provide appropriate interventions to minimize or prevent urinary tract infections (UTIs) for three residents with indwelling urinary catheters. For one resident with moderate cognitive impairment and a history of urinary retention, kidney disease, and previous UTIs, observations revealed that her catheter tubing was in direct contact with the carpeted floor before entering the collection bag. Her care plan included monitoring for signs of infection and ensuring proper catheter maintenance, but these interventions were not effectively implemented. Another resident with intact cognition and a diagnosis of neurogenic bladder was observed with her catheter tubing touching the floor tiles before entering the collection bag. Despite care plan instructions to monitor for catheter complications and change the bag as ordered, the resident experienced a period of no urinary output after receiving IV fluids, requiring catheter repositioning and flushing. She was subsequently treated for a UTI with antibiotics. A third resident with benign prostatic hyperplasia and urinary retention was repeatedly observed with his catheter tubing touching both outdoor patio cement and indoor carpeted floors while his catheter bag hung from his walker. Staff, including the DON and ADON, acknowledged that catheter tubing should not touch the floor and recognized the need for improved staff education and interventions. The facility did not have a specific policy on urinary catheters, and staff interviews confirmed awareness of UTI trends and the need for additional measures related to catheter care and placement.
Failure to Properly Label, Date, and Store Food and Utensils
Penalty
Summary
Surveyors observed multiple instances of improper food storage and handling in the facility's kitchen, including uncovered food items in refrigerators and freezers, such as drinks in adaptive plastic cups and various salads in bowls and plates. Food packages were found without labels to identify the product, open date, or use by date, including unidentified meat in a plastic zip lock bag and several bagged items in the freezer. Additionally, staff brought in several items in a grocery bag that were not dated or labeled. The ice scoop for the ice machine was observed stored on top of the machine without a container, rather than in a sanitary container as required. The facility's policy directed that all leftover food should be covered, labeled, and dated before refrigeration, but these procedures were not followed.
Inaccurate PBJ Staffing Data Submission Due to Coding Errors
Penalty
Summary
The facility failed to submit accurate staffing data to the CMS Payroll Based Journal (PBJ) system for the reporting period of October 1, 2024, to December 31, 2024. A review of daily assignment sheets and staff punch detail reports revealed multiple coding errors, including instances where Certified Nursing Assistants (CNAs) were incorrectly coded as Certified Medication Aides (CMAs), Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) were coded as CMAs, and administrative staff such as the MDS Coordinator and Assistant Director of Nursing (ADON) were coded as direct care staff for shifts they worked. These inaccuracies were found on numerous dates throughout the reporting period, affecting the accuracy of the facility's reported staffing levels, particularly on weekends. Interviews with facility leadership confirmed that staff working dual roles were expected to clock in under the correct job duty, and that the Office Manager and ADON were responsible for ensuring daily schedules matched employee punches. Despite these expectations, the errors persisted, and the facility's process involved a corporate staff member completing the PBJ submission after facility review. The facility's policy required timely and accurate PBJ submissions, but the observed discrepancies indicated a failure to meet this standard.
Failure to Provide Adequate Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, who required assistance with personal hygiene and ambulation. On the morning of July 4, 2024, Staff A, a Certified Nursing Assistant (CNA), assisted Resident #1 to the bathroom with a walker but left the resident unattended. As a result, Resident #1 lost balance and fell, sustaining a left hip fracture. The resident had a history of moderate cognitive impairment and required substantial assistance with activities of daily living, including toileting and ambulation. The care plan indicated the need for one-person assistance, which was not adhered to, leading to the fall. In a separate incident, Resident #2, who had severe cognitive impairment and a history of falls, was transported to a dental appointment without staff assistance. During the appointment, Resident #2 fell and sustained a dental fracture. The care plan for Resident #2 specified that a staff member or family should accompany the resident to appointments, but this was not followed, resulting in the fall and subsequent injury. Both incidents highlight a failure in the facility's supervision and adherence to care plans, which are critical for ensuring resident safety. The lack of staff presence during personal care tasks and appointments for residents with cognitive impairments and mobility issues directly contributed to the accidents and injuries sustained by the residents.
Inadequate Supervision During Medication Administration
Penalty
Summary
The facility failed to provide adequate supervision during medication administration for three residents. Resident #31, with mild cognitive impairment and a history of medically complex conditions, was left unattended with her medications on a tray table while she was in the bathroom. Staff E, a Certified Medical Assistant, left the medications in the room without ensuring Resident #31 took them, despite the facility's policy requiring staff to watch residents consume their medication. Additionally, Resident #31's roommate had a history of suicidal behavior, which further emphasized the need for supervision. In another instance, Staff G, a Registered Nurse, left a blood glucose monitor, lancets, and insulin pens unattended in Resident #46's room after performing a glucose test. This occurred while Resident #46 and her roommate were present. Furthermore, Staff G failed to close the computer screen, leaving Resident #46's information visible. Similarly, Staff F, a Certified Medication Aide, left a glass of water containing Miralax unattended at a dining table for Resident #19, without supervising her consumption. The Director of Nursing acknowledged the lack of a specific policy on leaving medications unattended but expected staff to follow professional standards of care.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe and appetizing temperatures for food served to residents. On May 21, 2024, a cook checked the temperature of 13 menu items on the steam table, all of which were above 135°F. However, when the first tray was placed on the delivery cart, the temperature of the broccoli was 99.0°F, the tater tots were 127.9°F, and the milk was 44.7°F. Later, the remaining food on the steam table was found to have temperatures of 117.2°F for chicken soup and 130.1°F for tomato soup. The facility's policy from 2021 required hot foods to be held and served at a minimum of 135°F and cold foods to remain below 41°F during the holding and plating process. The administrator acknowledged that the food should have been discarded and a new plate prepared for the resident.
Sanitary Practices and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary practices in food storage and preparation, as observed during a survey. Multiple refrigerators and freezers contained undated and unlabeled food items, including drinks, beef paste, strawberries, cheese, and other unidentified items. Additionally, the ice machine scoop was improperly stored without a barrier. These practices were not in accordance with the facility's Food Storage policy, which requires all refrigerated and frozen foods to be covered, labeled, and dated. Furthermore, staff members were observed not adhering to the facility's Food Safety and Sanitation policy, which mandates the use of hair restraints and beard nets. A Dietary Aide and a Maintenance Assistant were seen in the food preparation area without proper hairnets or beard coverings. Additionally, a Cook was observed handling food without following proper sanitary procedures. These actions were contrary to the facility's policies, which require thorough cleaning and sanitization of utensils and serving dishes prior to use.
Failure to Update PASARR for Resident with Serious Mental Disorder
Penalty
Summary
The facility failed to refer a resident with a Level I Preadmission Screening and Resident Review (PASARR) for a Level II evaluation despite the presence of a diagnosed serious mental disorder. The resident, identified as having moderate cognitive impairment, was diagnosed with several mental health conditions, including specific personality disorders, anxiety disorder, vascular dementia, and PTSD. The resident was also on antipsychotic and antidepressant medications. Despite these diagnoses and treatments, the facility did not update the PASARR to reflect the need for a Level II evaluation when new diagnoses were added. The resident's clinical record showed that the Level I PASARR completed in November did not require a Level II evaluation, as it documented no serious mental impairment at that time. However, subsequent diagnoses of specific personality disorders were added, and the resident was prescribed additional psychotropic medications. The facility lacked a policy for PASARR updates and did not conduct regular audits to ensure compliance with federal regulations. The administrator acknowledged the oversight and provided a new Level I PASARR during the interview, but the deficiency remained unaddressed at the time of the survey.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to maintain a safe environment by leaving a medication cart unlocked and unsupervised. During an observation, a Certified Medication Aide (CMA) left the medication cart unlocked and unattended while administering medications to a resident. The cart was positioned against the wall outside the resident's room and was out of sight from the room. In an interview, the Director of Nursing (DON) acknowledged the absence of a facility policy requiring staff to lock medication carts when not in sight. The DON expected staff to adhere to professional standards of care, which include keeping the medication cart locked at all times when away from it or when it is not visible.
Failure to Serve Correct Protein Portion Size for Pureed Diets
Penalty
Summary
The facility failed to serve the correct serving size of protein for three out of five residents who were on pureed diets. During an observation, Staff A prepared a pureed mixture of pork casserole, pineapple sauce, and bread, which was then measured to yield five cups. According to the pureed portion conversion chart, the required serving size was two #8 scoops, equating to 8 ounces. However, Staff A only served one #8 scoop of protein per plate, providing half of the required portion size. An observation at the end of the meal service showed that more than half of the pureed protein remained uneaten. The facility's Administrator confirmed that staff should adhere to the pureed conversion chart during meal service. The facility's Puree Process document directed staff to use the correct scoop size corresponding to the portion size, but this was not followed.
Infection Control Lapses in Medication Preparation and Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed in two separate incidents involving residents. In the first incident, a Certified Medication Aide (CMA) was observed preparing medication for a resident after coughing into her hands and blowing her nose without performing hand hygiene. This action was contrary to the facility's expectations, as stated by the Director of Nursing (DON), who emphasized the importance of hand hygiene before and after each medication pass, especially after coughing or blowing one's nose. In the second incident, a cook placed a resident's blanket in a shared sink while delivering a lunch tray, which was not in line with maintaining a sanitary environment. The resident involved had a history of severely impaired vision and required assistance with personal hygiene. The blanket was later observed back on the resident's legs and lying on the floor. The DON confirmed that the blanket should not have been placed in the sink, as per the facility's general guidelines policy, which directed staff to maintain a sanitary environment.
Confidentiality Breach During Medication Administration
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records during medication administration for two of the five residents reviewed. On May 20, 2024, a Certified Medication Aide left a glass of water containing Miralax unattended at a dining table for a resident, without supervising her consumption, in the presence of other residents. Additionally, a Registered Nurse conducted a blood glucose test and administered insulin to another resident but failed to secure the computer screen displaying the resident's information, leaving it visible to others. The Director of Nursing acknowledged the absence of a policy to ensure the computer screen's security when unattended and expected staff to adhere to professional standards of care.
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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