Aspire Of Gowrie
Inspection history, citations, penalties and survey trends for this long-term care facility in Gowrie, Iowa.
- Location
- 1808 Main Street, Gowrie, Iowa 50543
- CMS Provider Number
- 165344
- Inspections on file
- 23
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aspire Of Gowrie during CMS and state inspections, most recent first.
Staff failed to perform hand hygiene after handling a trash can lid and before preparing and serving a hot beverage to a resident, resulting in potential contamination. Additionally, expired milk was used for meal preparation, and multiple food items in storage were found open, unlabeled, undated, or improperly sealed, contrary to facility policy.
The facility failed to submit accurate PBJ staffing data to CMS, resulting in a report that showed insufficient licensed nursing coverage on multiple dates, despite internal records indicating 24-hour nursing services were provided by the DON and RNs. This discrepancy was linked to a change in management and issues with access to staffing information during the reporting period.
The facility had repeat deficiencies in its QAPI program, comprehensive assessments, psychotropic medication management (including PRN use and gradual dose reduction), and food sanitation practices. Surveyors found inaccurate MDS coding, lack of documentation for non-medical interventions before PRN antipsychotic administration, and improper food handling by staff, including failure to perform hand hygiene and improper glove use.
The facility did not complete required MDS entry and discharge assessments within mandated timeframes for four residents who experienced hospitalizations and returns, with documentation either incomplete or still in progress past deadlines. Staff interviews revealed a misunderstanding of assessment requirements, and affected residents had complex medical conditions and recent hospital stays.
The facility failed to accurately code medications and a UTI on MDS assessments for four residents. Errors included not documenting anticoagulant or antidepressant use when prescribed, incorrectly coding antiplatelet medications as anticoagulants, and omitting a UTI diagnosis despite antibiotic treatment. The DON acknowledged the MDS assessments were coded incorrectly.
A resident on a mechanical soft diet was served a meal that did not follow the approved menu, with substitutions made without full RD consultation. The current menu cycle also lacked RD review and signature, contrary to facility policy requiring menus to be reviewed and approved for nutritional adequacy.
Two residents with severe cognitive impairment experienced changes to high-risk medications without documentation that their representatives were notified or consented, despite facility policy requiring such communication. Staff interviews confirmed the expectation for notification, but clinical records lacked evidence that representatives were informed about the medication changes.
A resident with moderately impaired cognition was found with multiple medication cups containing topical creams at bedside, which he self-applied without a physician's order or documented assessment for self-administration. Staff were unaware of the resident's self-administration, and facility policy requiring assessment and secure storage of medications was not followed.
A resident with multiple psychiatric diagnoses did not receive an annual gradual dose reduction (GDR) for an antidepressant as required, and there was no documentation of behavioral monitoring or nonpharmacological interventions before an increase in antipsychotic medication. The DON confirmed the lack of required documentation and adherence to facility policy.
Two residents reported missing money from their personal belongings, but the facility did not notify DIAL or local law enforcement within the required timeframe. The Administrator and DON were either unaware of the missing money or failed to escalate the report, and the incidents were only reported to the Ombudsman. Facility policy requiring prompt reporting of suspected crimes was not followed.
A resident with severe cognitive impairment and multiple medical conditions was discharged to the hospital on several occasions without being offered or provided a Bed Hold notice, as required by facility policy. The clinical record lacked documentation of the notice, and the resident's representative confirmed it was not received. The Administrator was unable to locate the required documentation.
A resident with impaired cognition and multiple health conditions experienced several falls, but the care plan and CNA Kardex were not updated to reflect new fall interventions after each incident. Staff interviews and record reviews confirmed that required updates were not made, despite facility policy mandating care plan revisions when a resident's condition changes.
A resident with severe cognitive impairment and multiple medical conditions was observed with an indwelling urinary catheter, but the care plan lacked specific instructions for catheter management and the physician orders did not include a diagnosis for the catheter. The resident was repeatedly seen with catheter tubing and the drainage bag touching the floor, contrary to facility policy and DON expectations.
Three residents with respiratory conditions did not receive safe and appropriate respiratory care due to failures in documentation, equipment maintenance, and adherence to physician orders. Observations included undated or improperly stored oxygen and nebulizer tubing, lack of care plan direction for oxygen or CPAP use, and incomplete records for respiratory treatments. Staff were inconsistent in following facility policies for respiratory services, resulting in deficiencies in care.
The facility failed to correct deficiencies in their QAPI program and psychotropic medication documentation. A resident received a PRN psychotropic medication without proper documentation of behaviors and nonpharmacological interventions. The DON and ADM initially confirmed compliance with audits but later acknowledged the lack of documentation. Repeated deficiencies were identified in the QAPI program, accident prevention, unnecessary medication use, and notification of changes.
The facility failed to provide safe transfer techniques for two residents, leading to deficiencies in care. A resident with Alzheimer's and other conditions was transferred with only one staff member instead of the required two, while another resident with severe cognitive impairment was transferred without a gait belt. These actions were contrary to the care plans and facility policies, indicating a breach in safety protocols.
A facility failed to notify the Dietitian of a new admission and did not implement nutritional recommendations for a resident with severe cognitive impairment and multiple health conditions. The Dietitian's recommendations, which included dietary supplements and reweighing, were not communicated to the NP or acted upon, resulting in significant weight loss for the resident.
A facility failed to limit a PRN antipsychotic medication to 14 days and did not document non-medicinal interventions before administering the medication to a resident with Alzheimer's and bipolar disorder. The resident's care plan included strategies to manage aggression, but these were not documented as attempted before medication use. The facility's administrator acknowledged the oversight in protocol adherence.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent wound care for a venous ulcer on the right posterior lower leg. The facility failed to document treatments as ordered by the wound center, and the resident's condition worsened over time. Behavioral issues led to transportation refusals, preventing the resident from attending wound center appointments, and the facility did not ensure consistent in-house care.
The facility failed to correct deficiencies in professional standards, resident safety, QAPI program implementation, and food service practices, as identified in both current and past surveys. The Administrator acknowledged the issues, citing staffing challenges and efforts to improve oversight by reallocating the DON's responsibilities. Despite these efforts, the facility continued to struggle with compliance.
The facility did not comply with food service safety standards. A Cook/Dietary Aide was observed improperly handling apple pie by touching multiple surfaces with gloves and failing to cover the pie during transportation. The Food Service Supervisor confirmed that all food should be covered during transport and gloves should be changed after touching non-food surfaces, as per facility policy.
The facility failed to complete timely MDS assessments for two residents due to a management transition and staffing issues. The DON, who was not trained for the role, was responsible for MDS completion after the previous corporate MDS coordinator left. This led to delays in completing both an admission and an annual MDS assessment, contrary to the facility's policy.
A facility failed to complete a quarterly MDS assessment for a resident within the required timeframe. The last assessment was completed in August, and no subsequent assessment was done by December. The DON, who was not initially responsible for MDS, attempted to manage assessments while working on the floor. The facility plans to clarify roles for MDS completion.
A facility failed to accurately code the MDS assessment for a resident, resulting in a deficiency. The resident was admitted to hospice care, and their antipsychotic medication was discontinued, but the MDS did not reflect these changes. The DON acknowledged the coding errors during an interview.
A resident with no cognitive impairment and multiple diagnoses was discharged without a proper discharge planning process. The facility did not include discharge planning in the resident's care plans, and the clinical record lacked documentation of the resident's transfer wishes and contact participation. The resident was discharged to another facility without a documented transfer form, and the facility failed to communicate effectively with the desired facility.
A facility failed to provide a recapitulation of a resident's stay at discharge, as required by their policy. The resident, with a high BIMS score and a history of brain dysfunction, hemiplegia, stroke, dementia, Parkinson's, and seizures, was discharged to another facility. Documentation noted the resident took all belongings and was transported by a staff member, but lacked the required recapitulation.
A facility failed to provide adequate supervision, resulting in multiple falls for a resident with severe cognitive impairment and altercations involving another resident with aggressive behavior. The facility did not consistently notify families or physicians of incidents, nor did they implement effective interventions to prevent future occurrences.
A facility failed to provide an appropriate clinical rationale for declining a gradual dose reduction (GDR) for a resident's medication regimen. The resident, diagnosed with anxiety, depression, diabetes mellitus, and renal insufficiency, was receiving an antidepressant and an antipsychotic. The facility's assessment was incomplete, and the Psychiatric Subsequent assessment lacked documentation for the continued use of these medications, violating the facility's Medication Regimen Reviews policy.
A facility failed to document non-medical interventions before administering an as-needed antipsychotic to a resident with a history of dementia and aggressive behavior. Despite multiple incidents of aggression, records lacked documentation of non-pharmacological interventions or the effectiveness of the medication. The DON reported interventions like offering food or taking the resident back to his room, but these were not documented.
The facility failed to document the administration of an antipsychotic medication for a resident and did not record a fall for another resident. The MAR lacked the physician's order for the medication, and there was no follow-up documentation on its effects. Additionally, the fall incident was not recorded in the progress notes, and the resident's physician and family were not notified.
A facility failed to maintain a safe environment for a resident with severe cognitive impairment and open wounds. The care plan required enhanced barrier precautions (EBP), but no EBP signage or PPE supplies were observed. During wound care, the DON did not follow infection control protocols, including hand hygiene and gown use. Facility policies on MDRO, EBP, and hand hygiene were not adhered to, leading to a deficiency in infection control practices.
The facility failed to notify and document the physician and family for three residents regarding significant incidents. A resident with severe cognitive impairment experienced two falls without proper notification. Another resident reported verbal abuse by a CNA, but the primary physician was not informed. Additionally, a third resident's family was not notified of a facility-reported incident. These actions were contrary to the facility's policy requirements.
A facility failed to obtain a physician's order for Ready Wraps for a resident, despite instructions from a Lymphedema Clinic. The resident, who required assistance with dressing, did not have the wraps applied on several occasions. The DON acknowledged the omission from the Treatment Administration Records and Care Plan. Facility policy required physician orders for all treatments, but no order was placed for the Ready Wraps.
A facility failed to properly handle and document the destruction of medications for a resident, leading to a deficiency. A nurse admitted to discarding medications without proper documentation, contrary to the facility's policy, which requires detailed records and witness signatures for medication destruction.
The facility was found to have multiple deficiencies in food safety and storage, including unsanitary conditions and improper labeling and dating of food items. Observations revealed a build-up of dirt and debris in the kitchen and basement areas, along with several food items that were not labeled or dated, compromising food service safety standards.
The facility failed to submit accurate staffing data for the CMS PBJ Staffing Data Report, with multiple dates lacking 24-hour licensed nurse coverage. The DON, MDS Coordinator, and agency staff covered shifts, but did not clock in, leading to inaccuracies. The Administrator acknowledged the data did not reflect actual nursing hours worked.
The facility failed to address deficiencies in professional standards, accident prevention, and their QAPI program. Challenges include reliance on agency staffing and the DON's need to work on the floor, hindering her administrative duties.
A facility failed to follow physician orders for a resident requiring supervision during ambulation. Despite a history of falls and a physician's order for supervision when walking long distances, the resident's care plan lacked this information, and the resident continued to ambulate independently.
A resident with a history of repeated falls and cognitive impairments experienced 15 falls over six months due to the facility's failure to conduct a root cause analysis and implement effective interventions. Despite various measures like gripper strips and toileting schedules, the resident continued to fall, indicating inadequate supervision and intervention.
A resident with a history of constipation and bowel incontinence was hospitalized due to fecal impaction after the LTC facility failed to provide appropriate bowel management and physician notifications. Despite the resident's refusal of interventions like suppositories and enemas, the care plan lacked specific directions for managing bowel patterns. Progress notes showed gaps in documentation and communication, with no bowel assessments or physician notifications over several months, even as the resident experienced discomfort and abdominal pain. The facility's incontinence management policy was not effectively implemented, leading to a serious health event.
Failure to Maintain Sanitary Food Service and Proper Food Storage
Penalty
Summary
Staff failed to maintain sanitary conditions during food service, as observed when a dietary aide handled a trash can lid and then, without performing hand hygiene, proceeded to prepare and serve a hot beverage to a resident. The aide touched the handle of a cup, filled it with water, added hot chocolate mix, and stirred the drink with a straw, all after touching the trash can lid. The same hand was used to handle a scoop for powdered thickener, which was then placed back into the container without handwashing, and the prepared drink was served to a resident with the same straw. These actions were in direct violation of the facility's policy requiring hand hygiene after handling soiled equipment and before food preparation. Additionally, improper food storage practices were observed, including expired milk being used for meal preparation, open and unlabeled food items in the refrigerator and freezers, and dry goods stored in containers that were not properly sealed, labeled, or dated. The cook acknowledged using milk past its best by date, and the dietary manager confirmed the presence of unlabeled, undated, and expired food items. Facility policies required all food to be labeled, dated, and securely stored, which was not followed.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for the Payroll Based Journal (PBJ) Staffing Data Report covering the period from October 1 to December 31. The PBJ report indicated that the facility did not have licensed nursing coverage for 24 hours per day on 65 dates within the quarter, which triggered a deficiency for failing to meet the required staffing levels. However, a review of the facility's daily staffing sheets, nurse schedules, and time cards for the infraction dates showed that nursing services were provided for 24 hours per day, with coverage by the DON and several RNs. The deficiency was attributed to discrepancies in the PBJ data submission process. The facility underwent a change in management and corporation during the reporting period, resulting in a lack of access to staffing information for the earlier part of the quarter. After the management change, the process involved the Business Office Manager and Administrator submitting staffing data to the corporate PBJ software, with the corporation responsible for final submission. The facility relied on weekly detailed reports and corporate review to identify discrepancies, but the submitted PBJ data did not accurately reflect the actual staffing provided, leading to the deficiency.
Repeat Deficiencies in QAPI, Medication Management, and Food Sanitation
Penalty
Summary
The facility failed to correct previously identified deficiencies in four of fourteen areas of concern, as evidenced by repeat citations in multiple survey cycles. Specific deficiencies included failures in the QAPI program and plan, comprehensive assessments and their timing, appropriate use and documentation of psychotropic medications (including PRN use and gradual dose reduction), and food storage, preparation, and service sanitation. Surveyors observed inaccurate coding on the MDS for hospice level of care, antipsychotic and anticoagulant medication use, and urinary tract infection diagnosis. There were also failures to document non-medical interventions before administering PRN antipsychotic medications and to attempt gradual dose reductions as required. Additionally, staff were observed not following proper food safety protocols, such as failing to perform hand hygiene between touching contaminated surfaces and resident food items, and improper glove use during food service. Despite the facility's QAPI plan outlining a data-driven, proactive approach to quality improvement, these deficiencies persisted across several survey periods. The administrator acknowledged the repeat citations and described the facility's ongoing efforts to address these issues, but the report documents that the same types of deficiencies continued to be identified by surveyors.
Failure to Complete Timely MDS Entry and Discharge Assessments
Penalty
Summary
The facility failed to complete required Minimum Data Set (MDS) entry and discharge assessments within the mandated timeframes for four residents. Specifically, entry MDS assessments were not completed within 7 days for residents who were readmitted after hospital stays, and discharge MDS assessments were not completed within 14 days for residents who left the facility. Documentation showed that residents experienced hospitalizations and subsequent returns to the facility, but the necessary MDS tracking records, including entry and discharge assessments, were either incomplete or still listed as 'in progress' well after the required deadlines. Interviews and record reviews revealed that staff, including the DON, misunderstood the requirements for completing entry and discharge MDS assessments, believing they were not necessary for Medicaid residents unless the absence exceeded 10 days. The RAI Manual, however, requires these tracking records for all residents regardless of payer source or length of absence. The affected residents had complex medical histories, including conditions such as pneumonia, stroke, seizure disorder, and recent hospitalizations for acute symptoms, but the facility did not ensure timely completion and submission of the required MDS documentation.
Inaccurate MDS Coding for Medications and UTI
Penalty
Summary
The facility failed to accurately code medications and a urinary tract infection (UTI) on the Minimum Data Set (MDS) assessments for four out of fifteen residents reviewed. Specifically, one resident's Medication Administration Record (MAR) showed an order for apixaban, an anticoagulant, but their MDS assessment did not document receipt of an anticoagulant during the lookback period. Another resident's MAR listed trazodone, an antidepressant, but the MDS assessment did not reflect that the resident received an antidepressant, instead incorrectly indicating use of an antipsychotic. A third resident's MAR showed an order for clopidogrel bisulfate, an antiplatelet, but the MDS assessment incorrectly coded the resident as having received both an anticoagulant and an antiplatelet, contrary to the RAI manual instructions not to code antiplatelets as anticoagulants. Additionally, a fourth resident's MDS assessment indicated receipt of an anticoagulant, but the MAR did not show an order for such medication. This resident's MAR did include physician orders for antibiotics to treat a UTI, but the MDS assessment did not document the UTI during the lookback period. The facility's policy required that assessments be accurate and reflective of the resident's status at the time of assessment, completed by qualified staff. The DON acknowledged the MDS assessments were coded incorrectly.
Menu Not Followed and Lacked Dietician Approval
Penalty
Summary
The facility failed to follow the prescribed menu and obtain required Registered Dietician (RD) approval for menu changes and the current menu cycle. For one resident on a mechanical soft diet, the cook provided a lunch that substituted green beans for carrots and omitted baked beans, based on the Dietary Manager's (DM) decision. The DM stated that the RD approved omitting the baked beans without replacement, as the remaining items were considered nutritionally adequate. However, the RD later clarified that while she approved omitting the baked beans, she was not consulted about replacing carrots with green beans and would have required an additional carbohydrate, such as a potato, to meet nutritional needs. Additionally, the facility's current spring/summer menu lacked the RD's signature of approval. The RD reported she had not received the new menu for review and approval, and the last menu she signed was for the previous fall/winter cycle. The DM and Administrator believed the menus had been approved, but the RD confirmed she had not yet reviewed or signed the current menu. Facility policy requires menus to be prepared in advance, followed as written, and reviewed by the RD for nutritional adequacy, which was not done in this instance.
Failure to Notify Representatives of High-Risk Medication Changes
Penalty
Summary
The facility failed to notify the representatives of two residents with severe cognitive impairment about significant changes in their medication regimens. For one resident with diagnoses including anxiety, depression, and hypertension, a new order for quetiapine (an antipsychotic) was initiated, but there was no documentation that the resident's representative was informed or that consent was obtained. For another resident with Alzheimer's Disease, hypertension, and coronary artery disease, trazodone was discontinued and restarted at a different dose and frequency, yet again, there was no record of notification to the resident's representative regarding this medication change. Facility policy requires that residents or their representatives be informed of the benefits, risks, and alternatives prior to initiating or increasing medications, and that they have the right to refuse medications. Staff interviews confirmed the expectation that representatives should be notified of medication changes. However, clinical record reviews for both residents showed a lack of documentation of such notifications, constituting a failure to ensure that residents' representatives were fully informed about their health status, care, and treatments.
Failure to Assess and Authorize Resident Self-Administration of Topical Medications
Penalty
Summary
The facility failed to determine if a resident was capable of self-administering topical medications, as required by policy and clinical standards. A resident with moderately impaired cognition, as indicated by a BIMS score of 11, was observed with multiple unlabeled and labeled medication cups containing topical creams at his bedside, which he reported applying himself. The clinical record review showed that the resident had physician orders for several topical medications, including Triamcinolone, Diclofenac, and Hydrocortisone, but there was no physician order or documented assessment authorizing self-administration of these medications. The care plan noted the resident's preference to self-apply creams and lotions, but this intervention was added only after the issue was brought to the attention of the Director of Nursing. Staff interviews revealed a lack of awareness and oversight regarding the resident's self-administration of medications. One LPN stated she was responsible for applying the topical medications and was unaware the resident was self-administering them. The DON confirmed that the resident did not have an order or assessment for self-administration and acknowledged that medications should be kept in a secure place. Facility policy required a formal assessment of the resident's ability to self-administer medications and proper documentation, which was not completed in this case.
Failure to Complete Required GDR and Behavioral Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to complete an annual gradual dose reduction (GDR) for an antidepressant medication for a resident with diagnoses including depression, anxiety, and bipolar disorder. The clinical record showed that the last GDR for the resident's duloxetine was completed over a year ago, and there was no documentation of a more recent attempt, despite facility policy requiring annual GDRs after the first year of use. The pharmacy had recommended against a GDR, but the required documentation and process were not completed as per policy and CMS guidelines. Additionally, the facility did not document behavioral observations or the use of nonpharmacological interventions prior to increasing the resident's antipsychotic medication, aripiprazole. The resident's records, including behavior monitoring flow sheets and the MAR, lacked evidence of observed behaviors or attempted interventions before the medication increase. The DON confirmed the absence of this documentation and acknowledged the failure to follow required procedures.
Failure to Timely Report Missing Resident Money to Authorities
Penalty
Summary
The facility failed to report incidents of missing money belonging to two residents to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) and local law enforcement within the required 24-hour timeframe. In one case, a resident reported that her wallet, which contained approximately $14 and some change, went missing from her room and was later found without the money. The resident stated she informed the Administrator, but both the Administrator and the DON claimed they were only told about the missing wallet, not the missing money. In another case, a resident filed a grievance after discovering that money placed in her billfold and stored in her recliner was missing. The wallet, which previously contained bills and change, was found with only two quarters remaining. The Administrator acknowledged that, upon learning of the missing money, she contacted the corporate office and was instructed to investigate, report, and reimburse the resident. However, the Administrator admitted that the incidents were not reported to DIAL or local law enforcement as required by facility policy. Instead, the incident was reported to the Ombudsman, who visited the facility. The facility conducted an internal investigation, interviewing residents and staff, but could not determine who took the money. Facility policy mandates that any suspected crime against a resident must be reported to both DIAL and law enforcement, which was not followed in these cases.
Failure to Provide Bed Hold Notice Upon Hospital Discharge
Penalty
Summary
The facility failed to provide or offer a Bed Hold notice to a resident or the resident's representative upon discharge to the hospital, as required by facility policy and regulatory standards. Clinical record review showed that the resident, who had severe cognitive impairment and multiple complex medical diagnoses including pneumonia, viral hepatitis, wound infection, stroke, seizure disorder, traumatic brain injury, and respiratory failure, was discharged to the hospital on three separate occasions. There was no documentation in the clinical record that a Bed Hold notice was given during any of these hospitalizations. Interviews with the Administrator confirmed that the required Bed Hold documentation could not be located and that the resident's representative had not received the notice. Facility policy directed that Bed Hold information should be provided upon admission and at the time of transfer, including emergency transfers, and a copy should be filed in the resident's medical record. Despite these requirements, the necessary documentation and notification were not completed for this resident.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident following multiple falls, as required by policy and regulatory standards. Clinical record review showed that the resident, who had moderately impaired cognition and several diagnoses including hypertension, anemia, fibromyalgia, difficulty walking, unsteadiness, muscle weakness, and knee pain, experienced falls on multiple occasions. Incident reports documented falls in the resident's room, with immediate actions taken such as moving furniture and providing education to the resident. However, the care plan was not updated to reflect new interventions after falls on two specific dates, and the CNA Kardex was not revised to include these interventions for several fall events. Staff interviews confirmed that the care plan and Kardex were not updated after each fall, despite the facility's policy requiring ongoing assessment and revision of care plans as resident conditions change. The DON acknowledged the lack of updates, and both nursing and CNA staff reported relying on the Kardex for current care interventions. The deficiency was identified through clinical record review, staff interviews, and policy review, demonstrating a failure to ensure care plans were revised in response to changes in the resident's condition and fall history.
Failure to Provide Appropriate Catheter Care and Documentation
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. The resident, who was severely impaired in decision-making and had multiple diagnoses including pneumonia, viral hepatitis, wound infection, cerebrovascular accident, seizure disorder, traumatic brain injury, and respiratory failure, had physician orders for catheter care and output monitoring. However, the orders did not include a diagnosis for the catheter. The resident's care plan also lacked specific instructions for the management, assessment, handling, and maintenance of the indwelling catheter, as well as what to monitor while the catheter was in place. During observations, the resident was seen sitting in a wheelchair with the catheter bag hanging under the chair and the tubing touching the floor on multiple occasions. The DON confirmed that the care plan should address the indwelling catheter and that catheter tubing should be kept off the floor and coiled inside the privacy bag. Facility policy required documentation of the reason for catheter use and specified that catheter tubing and drainage bags should not touch the floor, but these procedures were not followed for this resident.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as evidenced by multiple deficiencies in the administration and documentation of oxygen therapy, nebulizer treatments, and CPAP use. For one resident with severe cognitive impairment and multiple respiratory diagnoses, staff did not document oxygen administration, frequency of oxygen saturation monitoring, or maintenance of respiratory equipment. Observations revealed improper storage and dating of oxygen and nebulizer tubing, with equipment found on the floor and not consistently changed or documented as required. Another resident with moderate cognitive impairment and diagnoses including COPD and sleep apnea had a physician order for oxygen at night, but the care plan lacked any direction for oxygen or respiratory services. The resident's room contained a CPAP machine without a corresponding physician order or documentation on its administration or maintenance. The resident reported not using the CPAP due to faulty equipment, and staff were unclear about the presence and use of an oxygen concentrator. Documentation in the medical record and on the MAR/TAR was incomplete regarding both oxygen and CPAP use. A third resident with respiratory failure and COPD was observed with oxygen tubing that was not dated as required, despite an order to change tubing and clean the concentrator filter weekly. The resident confirmed that tubing was changed only after being informed of a state visit, and extra tubing was left in the room. Facility policies required physician orders, proper dating, and documentation for respiratory equipment, but these were not consistently followed, leading to lapses in safe and appropriate respiratory care.
Deficiencies in QAPI and Psychotropic Medication Documentation
Penalty
Summary
The facility failed to correct deficiencies in four out of five areas of concern, as identified in a review of their Quality Assurance Performance Improvement (QAPI) policy, past surveys, and plan of correction audit forms. During an audit of psychotropic medication use, it was found that a resident received a PRN psychotropic medication without documentation of behaviors and nonpharmacological interventions. The Director of Nursing (DON) and the Administrator (ADM) initially confirmed compliance with the audits, but later acknowledged that the audits should not have been marked as compliant due to the lack of documentation. The survey identified repeated deficiencies in the facility's QAPI program and plan, accident prevention, unnecessary psychotropic medication use, and notification of changes. The facility's QAPI plan, effective August 2024, was intended to be comprehensive and data-driven, focusing on care outcomes and quality of life. However, the ADM acknowledged ongoing concerns with repeated deficiencies and expressed frustration despite efforts to improve, noting that the facility still employed some agency nurses but no longer used agency Certified Nurse Aides.
Failure to Adhere to Safe Transfer Techniques
Penalty
Summary
The facility failed to provide safe transfer techniques for two residents, leading to deficiencies in care. Resident #1, who was diagnosed with Alzheimer's, heart failure, muscle wasting, anxiety disorder, and depression, was assessed as requiring the assistance of two staff members and a gait belt for transfers. However, staff members were observed transferring Resident #1 with only one staff member, contrary to the care plan. Interviews with staff revealed a lack of awareness regarding the required assistance level for Resident #1, indicating a failure to adhere to the care plan. Similarly, Resident #5, who had severe cognitive impairment and required substantial assistance for transfers, was transferred without a gait belt by a single staff member. This was observed by the Administrator and Director of Nursing, yet the staff member acknowledged the oversight. The facility's policy mandates the use of appropriate techniques and devices, such as gait belts, for resident transfers, and staff are expected to follow the care plan. The failure to use a gait belt and adhere to the care plan for Resident #5's transfer represents a breach of the facility's safety protocols.
Failure to Implement Dietitian's Recommendations for Resident
Penalty
Summary
The facility failed to notify the Dietitian of a new admission, Resident #5, and did not implement the Dietitian's nutritional recommendations. Resident #5, who had severe cognitive impairment and multiple health conditions including diabetes, stroke, and chronic kidney disease, was admitted to the facility without the Dietitian being informed. The Dietitian, working remotely, provided recommendations via email on 1/27/25, which included adding a diet to the electronic health record, reweighing the resident, and increasing vitamin C and zinc supplements. However, these recommendations were not acted upon by the facility. The Director of Nursing (DON) acknowledged receiving the Dietitian's recommendations but failed to ensure they were communicated to the Nurse Practitioner (NP) or implemented. The DON did not recall the recommendations for Resident #5 and had no confirmation that the NP received them. As a result, Resident #5 did not receive the necessary dietary supplements and experienced significant weight loss, which was only noted after the Dietitian returned from vacation and reviewed the resident's weight records.
Failure to Limit PRN Antipsychotic Medication and Document Non-Medicinal Interventions
Penalty
Summary
The facility failed to adhere to regulations regarding the administration of PRN antipsychotic medications, specifically haloperidol, for a resident with complex medical conditions including Alzheimer's disease and bipolar disorder. The resident's care plan included non-pharmacological interventions to manage physical aggression, yet the facility did not document attempts of these interventions before administering the PRN medication. Additionally, the facility did not limit the PRN antipsychotic drug to 14 days as required, nor did they conduct an in-person exam to justify the continuation of the medication beyond this period. The resident's medication administration records showed that haloperidol was administered on multiple occasions over a span exceeding 14 days without the necessary documentation of non-medicinal interventions or an in-person exam. The facility's administrator acknowledged the oversight and confirmed the expectation for staff to document behaviors and attempt non-medicinal interventions prior to administering PRN antipsychotic medications. This lack of documentation and failure to follow protocol led to the identified deficiency.
Failure to Document and Provide Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary interventions and document treatments for a resident with a venous ulcer on the right posterior lower leg. The resident, who had severe cognitive impairment and multiple medical conditions, including hypertension, septicemia, and malnutrition, was dependent on staff for mobility and care. Despite having a care plan in place, the facility did not complete or document the required treatments for the resident's wound, as evidenced by missing entries in the Treatment Administration Record (TAR) and clinical records from late September to mid-November. The resident's wound, which was being treated at a wound center, showed signs of deterioration over time, with measurements indicating an increase in size and the presence of necrotic tissue. The wound center provided specific instructions for wound care, including cleansing with saline and applying specific dressings, but the facility failed to document these treatments consistently. The resident's condition was further complicated by behavioral issues that led to transportation refusals, preventing the resident from attending scheduled wound center appointments. Interviews with facility staff and wound center personnel revealed that the facility was aware of the resident's treatment needs but failed to ensure consistent care. The Director of Nursing acknowledged the lack of documentation and treatment, attributing it to transportation issues and the resident's behavior. The wound center nurse confirmed that the resident's wound worsened due to comorbidities and lack of care, and the facility was expected to perform treatments per physician orders, which were not documented as completed.
Repeated Deficiencies in Professional Standards and Resident Safety
Penalty
Summary
The facility failed to correct deficiencies in four areas of concern, as identified in both the current and past surveys. These areas include ensuring services meet professional standards, maintaining an environment free of accidents and hazards with adequate supervision, implementing an effective QAPI program, and adhering to proper food procurement, storage, preparation, service, and sanitation practices. Despite having a QAPI plan in place, the facility did not successfully address these deficiencies, indicating a gap in their quality improvement processes. The Administrator acknowledged the repeated deficiencies and expressed surprise, believing the issues had been resolved. She noted challenges in staffing, particularly in hiring nurses, which led to the use of agency staff, a solution the facility was not satisfied with. The Administrator mentioned efforts to have the DON focus more on administrative duties rather than floor duties, with the goal of improving oversight and addressing physician orders. Despite these efforts, the facility continued to face significant obstacles in maintaining compliance with professional standards and ensuring resident safety.
Failure to Follow Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the preparation and distribution of food. On December 2, 2024, Staff A, a Cook/Dietary Aide, was observed plating apple pie while wearing gloves. However, Staff A touched multiple surfaces, including plates, a pie pan, and a counter, while plating the pie, which is against the facility's policy that requires gloves to be changed after touching surfaces other than ready-to-eat food. Additionally, during the noon meal, Staff A transported room trays down the hallway with two out of three servings of apple pie uncovered, contrary to the facility's policy that mandates all food be covered during transportation. On December 3, 2024, the Food Service Supervisor confirmed that all foods should be covered when transported to a resident's room and that gloves should only be used for handling ready-to-eat food, necessitating a change if other surfaces are touched. The facility's policies on Preventing Illness Employee Hygiene and Sanitary Practices and Food Preparation and Service, both revised in October 2023 and October 2024 respectively, were not followed, leading to this deficiency.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days of admission for one resident and did not complete a comprehensive annual assessment in a timely manner for another resident. The clinical record review and staff interviews revealed that the facility did not adhere to the required timelines for completing the Minimum Data Set (MDS) assessments. Specifically, one resident's admission MDS was not completed or started within the required timeframe, and another resident's annual MDS was also incomplete and overdue. The Director of Nursing (DON) reported that the previous management had a corporate MDS coordinator responsible for completing the MDS assessments. However, after a transition in management, the responsibility fell on the DON, who was not adequately trained for the role and was also working as a charge nurse. The administrator confirmed that the transition led to a lack of clarity regarding the responsibility for MDS completion, resulting in delays. The facility's policy required comprehensive assessments within 14 days of admission and annually, but these were not met due to the management transition and staffing issues.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for one resident within the required timeframe. Specifically, the review of the electronic health record for a resident showed that the last quarterly MDS was completed on August 17, 2024, and there was no subsequent quarterly MDS assessment completed after that date. This oversight was identified during a record review conducted on December 4, 2024. The facility's policy, effective October 2024, assigns the responsibility of ensuring timely resident assessments to the Assessment Coordinator. However, the Director of Nursing (DON) stated that when she assumed her role, the responsibility for MDS assessments was not included, as someone from corporate was handling them. The DON, who routinely worked on the floor, attempted to complete the MDS assessments but acknowledged the need for a meeting to clarify roles and responsibilities for completing the MDS assessments. The facility had a census of 15 residents at the time of the review.
MDS Coding Inaccuracy for Hospice and Antipsychotic Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident was admitted to hospice level of care on June 27, 2024, and had their antipsychotic medication, Risperdal, discontinued on July 27, 2024. However, the MDS assessment did not document the resident's hospice level of care and incorrectly indicated that the resident took an antipsychotic medication during the lookback period. This discrepancy was acknowledged by the Director of Nursing (DON) during an interview, who confirmed that the MDS was not coded correctly regarding hospice care and the antipsychotic medication.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to implement a discharge planning process for a resident who was discharged to another nursing facility. The resident, who had a BIMS score of 14 indicating no cognitive impairment, had multiple diagnoses including non-traumatic brain dysfunction, hemiplegia, stroke, non-Alzheimer's dementia, Parkinson's, and a seizure disorder. Despite the resident's mental capacity to make decisions, the facility did not include discharge planning in the Baseline Care Plan or the Care Plan in effect at the time of discharge. The clinical record also lacked documentation of the resident's wish to transfer and did not show that the resident's contact participated in the discharge planning. The facility's progress notes indicated that the resident's primary care provider was aware of the discharge, but the facility awaited signed orders. The resident was discharged to another nursing facility without a documented transfer form, and the discharge was facilitated by a staff member using their personal vehicle. An email from the DON confirmed that the resident had requested to move closer to their spouse, but the facility failed to return phone calls from the desired facility. The facility's policy required a discharge summary and post-discharge plan to assist the resident in adjusting to a new living environment, which was not developed in this case.
Failure to Provide Recapitulation of Resident's Stay at Discharge
Penalty
Summary
The facility failed to ensure a recapitulation of a resident's stay at the time of discharge, which is a requirement according to their policy. Resident #6, who had a high Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment, was discharged to another nursing facility. The resident had a medical history that included non-traumatic brain dysfunction, hemiplegia, stroke, non-Alzheimer's dementia, Parkinson's, and a seizure disorder. The discharge was documented in a progress note, which stated that the resident took all their belongings and was transported in a staff member's personal vehicle, with all signed paperwork sent with the resident. However, the clinical record did not include a recapitulation of the resident's stay, which is a necessary component of the discharge summary as per the facility's policy revised in November 2017.
Inadequate Supervision Leads to Falls and Altercations
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and incidents for two residents. One resident, who had severe cognitive impairment and was dependent on staff for mobility and toileting, experienced multiple falls. The facility's incident reports documented several falls where the resident attempted to pick up items from the floor without assistance, resulting in falls from their wheelchair. The facility did not consistently notify the resident's family or physician of these falls, nor did they implement effective interventions to prevent future incidents. Another resident, who had severe cognitive impairments and a history of aggressive behavior, was involved in multiple altercations with other residents. The resident exhibited physical and verbal aggression, including pulling another resident's headphones and jabbing a spoon towards a resident's face. Despite these behaviors, the facility did not provide adequate supervision to prevent these altercations, and staff interventions were reactive rather than preventive. The facility's policies required notification of the physician and family after falls, as well as the implementation of new interventions and documentation in the resident's medical record. However, these steps were not consistently followed, and the facility failed to identify trends or conduct root cause analyses to address the underlying issues. The lack of effective supervision and failure to implement preventive measures contributed to the ongoing incidents and altercations.
Failure to Provide Clinical Rationale for Medication Regimen
Penalty
Summary
The facility failed to provide an appropriate clinical rationale for declining a gradual dose reduction (GDR) for a resident's medication regimen. The resident, who was diagnosed with anxiety, depression, diabetes mellitus, and renal insufficiency, was receiving both an antidepressant and an antipsychotic medication. The facility's Minimum Data Set (MDS) assessment for the resident was incomplete, lacking a Brief Interview for Mental Status (BIMS) score and staff assessment for cognitive patterns. The Clinical Physicians Orders included prescriptions for quetiapine fumarate and sertraline, but the Consultation Report regarding the GDR request for quetiapine was incomplete. The Psychiatric Subsequent assessment lacked documentation of the clinical rationale for the continued use of these medications. The Director of Nursing (DON) indicated that the physician addressed GDRs in progress notes or the Psychiatric Subsequent Assessment, but the review of the assessment did not provide sufficient documentation. The facility's Medication Regimen Reviews policy required the consultant pharmacist to review medication regimens following state and federal guidelines, including the need for GDRs and behavioral interventions unless contraindicated. However, the facility did not adhere to these guidelines, resulting in the deficiency.
Failure to Document Non-Medical Interventions Before Administering Antipsychotic Medication
Penalty
Summary
The facility failed to document non-medical interventions prior to administering an as-needed antipsychotic medication to a resident. The resident, who had a history of non-Alzheimer's dementia, seizure disorder, anxiety disorder, bipolar disorder, and intermittent explosive disorder, exhibited aggressive behaviors towards other residents. Despite these behaviors, the facility's records lacked documentation of any non-pharmacological interventions attempted before administering haloperidol, an antipsychotic medication. Additionally, there was no documentation of adverse drug reactions, side effects, or the effectiveness of the medication. Observations and staff interviews revealed multiple incidents involving the resident's aggressive behavior, such as pulling another resident's headphones, turning lights on and off, and jabbing a spoon towards another resident's face. The facility's Director of Nursing (DON) reported that non-medical interventions included offering food or taking the resident back to his room, but these were not documented in the progress notes. The Treatment Administration Record (TAR) and Point of Care Response History also lacked documentation of the resident's behaviors or any behavioral interventions attempted on the day the medication was administered.
Documentation Failures in Medication Administration and Fall Reporting
Penalty
Summary
The facility failed to maintain accurate documentation of medical records for two residents, leading to deficiencies in care. For one resident, the facility did not document the administration of an as-needed antipsychotic medication, haloperidol, which was given to manage aggressive behaviors. The Medication Administration Record (MAR) lacked the physician's order for the medication, and there was no documentation of non-medicinal interventions, adverse drug reactions, side effects, or the effectiveness of the medication. The Director of Nursing (DON) acknowledged the oversight in not entering the order into the MAR, which resulted in a lack of follow-up on the resident's condition after receiving the medication. For another resident, the facility failed to document a fall in the progress notes or notify the resident's physician and family. The resident, who had severe cognitive impairment and was dependent on staff for mobility, was found on the floor after attempting to pick something up. The incident report and clinical record did not include necessary details such as the condition of the resident when found, assessment data, or notification of the physician and family. The DON confirmed that the agency nurse did not complete all required documentation steps following the fall.
Inadequate Infection Control Practices for Resident with Open Wounds
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections for a resident with severe cognitive impairment and multiple medical conditions, including a venous ulcer and cellulitis. The resident was dependent on staff for mobility and toileting, and the care plan included enhanced barrier precautions (EBP) due to open wounds. However, during the survey, it was observed that there was no EBP signage on the resident's door, and personal protective equipment (PPE) supplies were not maintained outside the room as required by the care plan. During a wound care procedure, the Director of Nursing (DON) did not follow proper infection control protocols. The DON did not perform hand hygiene before putting on gloves, used the same pair of gloves throughout the procedure without changing them, and did not perform hand hygiene after removing the gloves. Additionally, the DON did not wear a gown during the procedure, which was acknowledged as a requirement for high-contact resident care activities. The DON also used a gown intended for personal protection as a barrier for supplies instead. The facility's policies on multidrug-resistant organisms (MDRO), enhanced barrier precautions, and hand hygiene were not adhered to during the care of the resident. The policies required the use of gloves and gowns during high-contact activities and emphasized hand hygiene as the primary means to prevent infection spread. The facility's failure to implement these precautions and protocols contributed to the deficiency in providing a safe and sanitary environment for the resident.
Failure to Notify Physicians and Families of Incidents
Penalty
Summary
The facility failed to notify and document the physician and family for three residents regarding significant incidents affecting their care. Resident #3, who had severe cognitive impairment and multiple medical conditions, experienced two falls. The first fall occurred when the resident was found on the floor after attempting to retrieve something from his wheelchair. Although the incident report noted that the administrator, DON, and physician were notified, there was no documentation of family notification. In a second incident, the resident fell again while trying to pick something up, but neither the physician nor the family was notified. The facility's policy required notification of both the physician and family after a fall, which was not adhered to in these cases. Resident #11, with moderately impaired cognition and several medical diagnoses, reported verbal abuse by a CNA. The facility documented the incident and took action by suspending the CNA and conducting follow-ups with the resident. However, the clinical record lacked documentation of notification to the resident's primary physician about the abuse allegations. The DON acknowledged the oversight, having only contacted the mental health provider, who later had no recollection of the incident. The facility's policy mandated prompt notification of the physician and resident representative for changes in the resident's condition or status, which was not followed. Resident #9, also with severe cognitive impairment and multiple health issues, was involved in a facility-reported incident. The electronic health record did not show family notification for this incident. The DON admitted that the family was not informed until the outcome of the incident was clear. A text message exchange between the administrator and a family member revealed uncertainty about whether a medication error related to the incident was discussed. The facility's failure to notify the family promptly was contrary to their policy requirements.
Failure to Obtain Physician's Order for Ready Wraps
Penalty
Summary
The facility failed to obtain a physician's order for the application of Ready Wraps, specialized wraps used to manage edema, for a resident. The resident, who had intact cognition and required substantial assistance with dressing, was instructed by an Occupational Therapist at a Lymphedema Clinic to use the Ready Wraps. However, the facility did not contact the physician to secure an order for their use. The Treatment Administration Records for October, November, and December 2024 did not include an order for the application and removal of the Ready Wraps. Observations and interviews revealed that the resident did not have the wraps applied on multiple occasions, despite needing assistance from staff to do so. The Director of Nursing (DON) acknowledged that the wraps were not listed on the Treatment Administration Records or the Care Plan and stated that they would be added. The facility's policy required that all medication and treatment protocols be ordered by the resident's attending physician or designee, and that all physician's orders be appropriately transcribed and noted by a licensed nurse. The facility administrator confirmed that no order had been placed for the Ready Wraps, despite instructions from the Lymphedema Clinic.
Improper Medication Destruction and Documentation
Penalty
Summary
The facility failed to properly handle the destruction of medications for one resident, leading to a deficiency in pharmaceutical services. During a facility investigation, it was revealed that the facility did not maintain a record of medications returned to the pharmacy, except for 35 tablets of Depakote. A registered nurse admitted to tearing the top off the bubble pack, punching out the remaining medications, and discarding the bubble pack without proper documentation. The nurse stated she destroyed the leftover medication in the drug buster but did not document the destruction as required by the facility's policy. The facility's policy on discarding and destroying medications requires that medications not returned to the pharmacy be destroyed according to state regulations, with a medication disposition record signed by witnesses. This record must include details such as the resident's name, date of destruction, medication details, and method of destruction. However, the nurse involved was unaware of the requirement to return medications to the pharmacy and failed to document the destruction process, leading to a breach in the facility's medication management protocol.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of unsanitary conditions and improper food storage practices. During an inspection, a build-up of dust, dirt, and debris was noted along the side of the oven, on the floor beside and behind the oven, and along the floor and baseboard near the kitchen's main door. Additionally, dried food and debris were found inside the kitchen refrigerator, and several food items, including a cheese sandwich, mayonnaise, non-fat vanilla yogurt, beef soup base, and shredded mild cheddar cheese, were not labeled or dated as to when they were opened. Further observations revealed unsanitary conditions in the basement area, where a brown, sticky substance, dirt, and debris were found, along with opened frozen hot dog buns that were not dated. The chest freezer in the basement contained a build-up of dirt, debris, frost, and ice, and an opened, unlabeled, and undated box with a plastic bag containing pizza crusts. Additionally, a plastic bag with frozen pre-made omelettes and a box of opened ice cream sandwiches were not labeled or dated. Gallon jugs of white and chocolate milk, as well as two pitchers of juice, were also found without labels or dates in a serving bin with ice near the kitchen's North door.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing data for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period from January 1 to March 31. The report identified multiple dates where there was a failure to have licensed nurse coverage 24 hours a day. The facility's daily assignment sheets indicated that the Director of Nursing (DON), MDS Coordinator, and agency staff covered the nursing shifts on these dates. However, the salaried and agency staff did not clock in and out, leading to inaccuracies in the reported staffing data. The Administrator acknowledged that the data submitted for the PBJ did not accurately reflect the nursing hours worked by the nursing administration and agency staff. The facility had a procedure in place for salaried nurses to fill out a missed punch form, which was then sent to the HR manager or Administrator and subsequently to the Payroll Department for recording on the PBJ dashboard. Despite this procedure, the failure to ensure accurate data submission resulted in the deficiency noted in the report.
Facility Fails to Correct Deficiencies in QAPI and Care Standards
Penalty
Summary
The facility failed to correct deficiencies in three of six areas of concern, as identified in their Quality Assurance Performance Improvement (QAPI) plan and past surveys. The deficiencies included services not meeting professional standards, lack of accident/hazard prevention and supervision, and issues with the QAPI program/plan itself. The facility's mission is to maximize the quality of resident care and services through a systematic and interdisciplinary approach, but they have not achieved this due to ongoing issues. The Regional Nurse Consultant noted challenges with agency staffing, as temporary staff only perform their immediate tasks, and the Director of Nursing (DON) is often required to work on the floor, preventing her from fulfilling her administrative duties.
Failure to Provide Supervision During Ambulation
Penalty
Summary
The facility failed to provide professional standards of care by not adhering to physician orders for a resident requiring supervision during ambulation. The resident, who had diagnoses of non-Alzheimer's disease, anxiety disorder, and depression, was assessed as rarely or never understood, and had a history of numerous falls over the past six months. Despite a physician's order dated February 7, 2024, for the resident to have supervision when walking long distances in the hallway, the facility did not implement this order. The resident's care plan also lacked information regarding the need for supervision with ambulation, resulting in the resident continuing to ambulate and transfer independently without the required supervision.
Failure to Conduct Root Cause Analysis and Implement Effective Fall Interventions
Penalty
Summary
The facility failed to conduct a root cause analysis or determine a conclusion for each fall experienced by a resident, who had a history of repeated falls, totaling 15 incidents in the previous six months. The resident, identified as having a risk for falls due to dementia and the use of psychotropic medication, had severely impaired decision-making skills and memory problems. Despite the implementation of various interventions, such as gripper strips, encouraging the use of glasses, and toileting schedules, the resident continued to experience falls, indicating a lack of effective intervention and supervision. The facility's policy on fall prevention aimed to reduce fall risks through a comprehensive assessment and intervention strategy. However, the facility did not adequately implement these strategies for the resident in question. The Director of Nursing and Regional Nurse Consultant mentioned using the 'five whys' method for root cause analysis, but the continued falls suggest that this process was either not effectively carried out or the interventions were not appropriately tailored to the resident's needs. The facility's failure to provide adequate supervision and effective interventions as directed by the Care Plan contributed to the ongoing fall incidents.
Inadequate Bowel Management Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate bowel management assessments, interventions, and physician notifications for a resident, leading to a fecal impaction and subsequent hospitalization. The resident, who had a history of constipation and was always incontinent of bowel and bladder, refused bowel management interventions such as suppositories and enemas. Despite this, the care plan lacked specific directions on how to manage the resident's bowel patterns, including when to notify the physician about constipation issues. The progress notes revealed significant gaps in documentation and communication. Over several months, the resident went multiple days without a bowel movement, sometimes up to 19 days, without proper bowel assessments or physician notifications. The staff documented refusals of interventions but failed to follow up with alternative strategies or notify the physician about the resident's ongoing constipation and refusal of care. This lack of action and documentation persisted even when the resident showed signs of discomfort and abdominal pain. The situation escalated when the resident experienced severe abdominal pain, nausea, and shortness of breath, leading to an emergency hospital visit. Hospital records confirmed a fecal impaction and significant abdominal distention. The facility's policy on incontinence management was not effectively implemented, as there were no standing orders for constipation, and the staff did not consistently assess or document the resident's bowel condition. The facility's failure to manage the resident's bowel care appropriately resulted in a serious health event requiring hospitalization.
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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