Bettendorf Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bettendorf, Iowa.
- Location
- 2730 Crow Creek Road, Bettendorf, Iowa 52722
- CMS Provider Number
- 165280
- Inspections on file
- 34
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Bettendorf Health Care Center during CMS and state inspections, most recent first.
Multiple dependent residents experienced prolonged waits for assistance after activating their call lights, with reports of waiting from over an hour to several hours for help with toileting, incontinence care, transfers, and going to bed. Cognitively intact residents and their families described repeated episodes where call lights were left unanswered, staff entered rooms only to turn off call lights and not return, and residents had to call the nurses’ station multiple times or yell in the hallway for help. Direct observations showed call lights remaining on for 25–31 minutes while staff, including an RN, the DON, and other personnel, walked past the room without checking on the resident. Staff interviews revealed inconsistent adherence to the facility’s call light policy, which required all staff to respond to activated call lights and promptly address resident needs.
Two residents with intact cognition were not treated with dignity and respect when staff failed to honor their expressed wishes during care and smoking-related interactions. One resident, dependent on staff for hygiene and with skin integrity issues, reported that a CNA scrubbed her hip and abdomen roughly during bathing, continued despite her requests to stop, and caused bleeding, contrary to the care plan directing gentle washing. Another resident with alcoholic polyneuropathy and gait instability, who questioned why others could smoke, reported that a Social Worker took his unlit cigar while he was on the porch with a visitor and planning to leave the property to smoke, and attempted to take the visitor’s cigarettes, actions the resident perceived as demeaning and treating him like a child.
A resident with mild cognitive impairment, multiple medical diagnoses, and a physician order for scheduled DuoNeb nebulizer treatments was repeatedly observed using the nebulizer without staff present, including times when the mask lay on the bed or floor while the machine was running or was held far from the mouth. The care plan documented impaired cognition and the need for supervision and task segmentation, and an intervention to administer treatments as ordered, yet there was no documented self-medication assessment, no care plan direction for self-administration, and no physician order authorizing self-administration, contrary to facility policy requiring an IDT assessment and documentation before allowing self-administration of medications.
A resident with intact cognition and expressive aphasia alleged that a CNA yelled at her, called her names, took her soda, and pushed her in the chest/shoulder area during incontinence care, while she believed two staff should have been present. Nursing staff and an LPN assessed her and found no physical injuries, and the CNA reported she only held the resident at the waist to prevent a slip and that the resident sometimes "plops" into her chair. The Administrator reported interviewing some staff and several residents on the same hall, but did not obtain written statements, did not interview all staff who worked that night, and some CNAs and residents later denied being interviewed about rough or abusive care. Facility policy required obtaining witness statements from all known witnesses and thorough investigation of abuse allegations, but the limited interviews and lack of complete documentation resulted in an incomplete investigation of the resident’s abuse allegation.
A resident with alcoholic polyneuropathy, generalized muscle weakness, unsteadiness, psoriasis, and hand arthritis was discharged from the hospital and later seen in a geriatric clinic with documented recommendations and orders for rheumatology and podiatry evaluations. Over more than seven months in the facility, the resident reported not seeing either specialist despite ongoing itchy, raised, dark pink skin lesions on both arms. The Administrator acknowledged that the rheumatology referral, though ordered at admission, was not actively pursued until months later due to Medicaid coverage issues and competing priorities, and that a podiatry appointment was missed when coverage was not in place and a subsequent appointment did not occur for unknown reasons. The DON stated she expected staff to follow physician orders and ensure residents were placed on the podiatrist’s list, which did not occur in this case.
A resident with ESRD on hemodialysis, diabetes, and paraplegia was not consistently transported to dialysis on time and did not receive fully documented pre- and post-dialysis assessments as ordered. The resident reported being late to dialysis once or twice weekly, arriving after the expected chair time, and dialysis staff confirmed at least one missed transport due to the resident not being ready. Review of the MAR showed repeated omissions in required assessments of thrill, bruit, access site condition, cognition, and weight on multiple dialysis days, with no explanations in the record. Facility leadership and nursing staff described expectations for timely readiness for transport and comprehensive post-dialysis assessments, but the documentation and resident reports demonstrated that these expectations were not met.
The facility failed to ensure proper storage and documented disposition of discontinued and leftover medications after resident death or discharge. Staff reported that for two to three years, the DON kept discontinued medications in an unlocked cupboard in her office and stored discontinued narcotics in a locked desk drawer without inventory or shift-to-shift counts. Multiple staff, including an ADON, LPNs, and the HR Manager, observed 20–30 medications and narcotics in these locations, and the Administrator acknowledged that the DON had given a medication from this cupboard to a CNA. For three residents, the facility could not provide documentation that medications dispensed in blister-packs and other forms were either destroyed or returned to the pharmacy, despite policies requiring discontinued medications to be removed from active use, stored in a separate locked area, and destroyed or returned with proper documentation and witnesses.
A resident with complex medical and mental health needs was discharged after signing an AMA form without being adequately educated on discharge options or prepared for a safe transition. The resident, who required assistance with daily living and medication management, left for a homeless shelter without medications or a clear care plan, resulting in a subsequent hospitalization. Staff interviews confirmed that no alternative discharge plans were discussed and that the resident did not fully understand the AMA process.
The facility failed to provide scheduled bathing services to four residents, as per their care plans and preferences. One resident reported not being offered a bath or shower for over a week after refusing one due to feeling unwell. Another resident, preferring weekly showers, did not receive one for five weeks until she mentioned it to therapy staff. A third resident could not recall the last time he had a bath or shower, with no documentation since his recent hospitalization. A fourth resident, preferring bed baths twice weekly, reported inconsistencies in receiving them. The ADON acknowledged the issue and implemented changes to the staff assignment sheet.
The facility failed to maintain three shower rooms in a sanitary condition, with missing tiles, dirty grout, and residue buildup observed. Staff interviews revealed a lack of awareness and unclear responsibilities for cleaning and maintenance. The facility's policy on providing a safe and homelike environment was not followed, leading to unsanitary conditions.
The facility failed to respond to resident call lights within the expected timeframe, leading to a deficiency in meeting resident needs. A resident with intact cognition reported prolonged response times, and another resident with mild cognitive impairment experienced a delay of over 30 minutes in receiving assistance. Despite staff presence at the Nurses Station, call lights were not promptly addressed, highlighting a systemic issue in timely resident care.
A facility failed to consistently assess and monitor a resident's condition before and after dialysis treatments. Despite the resident's intact cognition and regular dialysis schedule, the care plan lacked specific interventions for pre- and post-dialysis assessments. Staff interviews and record reviews revealed inconsistent documentation practices, with only one post-dialysis assessment recorded in the previous month.
A resident with memory impairment and moderate decision-making impairment did not receive adequate nail care, resulting in long, thick, and yellow toenails. Despite family requests, no action was taken. Staff interviews revealed a lack of clarity on responsibilities for toenail care, compounded by the absence of a podiatrist since the previous one retired.
A resident with a history of dysphagia and a physician's order to eat under supervision was observed eating unsupervised in her room. Despite being on isolation due to MRSA, staff interviews and observations confirmed that the resident was left alone during meals, contrary to the care plan and physician's directives.
The facility failed to maintain proper catheter care for a resident, with observations showing the Foley catheter bag and tubing frequently touching the floor. Additionally, inadequate incontinent care was provided to another resident, with a CNA failing to cleanse necessary areas due to understaffing. Staff interviews confirmed expectations for proper care were not met.
The facility failed to prepare pureed food to the correct texture for two residents, as observed during a survey. The Dietary Manager confirmed the inconsistency, and staff reported previous complaints about the kitchen. The facility's policy on pureed food preparation was not followed, affecting residents with specific dietary needs due to conditions like dysphagia.
The facility was cited for repeated deficiencies in areas such as Activities of Daily Living, accident hazards, bowel/bladder incontinence, and sufficient nursing staff. Despite having a QAPI plan and monthly meetings to address issues, the facility failed to effectively correct these deficiencies, as evidenced by repeated citations in recent years.
A medication error occurred when a CMA mistakenly administered another resident's medications, leading to a significant adverse event. The resident, with a history of hypertension, renal insufficiency, and seizure disorder, received medications including Cefadroxil, L-Arginine, Trazodone, Tamsulosin, Baclofen, and Melatonin. This resulted in acute encephalopathy and hypotension, requiring intubation and ICU admission. The error was due to a failure in following medication administration protocols.
A facility failed to provide physical therapy services as per physician orders for a resident. The resident was supposed to receive therapy five times a week, but records showed they only received it once or twice during certain weeks. Despite progress noted by the PTA, the prescribed therapy frequency was not met, resulting in a deficiency.
Failure to Respond Timely to Resident Call Lights for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident call lights in a timely manner for multiple dependent residents who required staff assistance for activities of daily living. One resident with cellulitis, lymphedema, and bowel incontinence, cognitively intact with a BIMS score of 15, reported having to wait more than a few hours, sometimes up to 3 hours, for staff to answer her call light, particularly on night shift. She stated staff were supposed to check and change her every 2 hours, but this did not consistently occur. She also reported that staff often took more than 15 minutes to answer her call light at least once a week, and that staff would sometimes enter, turn off the call light, say they would return, and then never come back. A CNA confirmed that this resident had complained about untimely call light responses and stated that staff were expected to answer call lights within 15 minutes and that any staff member should respond. Another cognitively intact resident, dependent on staff for toileting, transfers, and personal hygiene, experienced prolonged waits for assistance. A family representative reported that this resident was incontinent of urine and had to wait an hour and a half for staff to come to her room, and that staff told the resident they had other patients to care for. The family representative also described an incident where the resident turned on her call light at 8:00 PM to get into bed and was not assisted until 11:00 PM. A CNA reported that this resident complained of being left sitting in her wheelchair until 11:00 PM, with her call light on for 2 hours before staff helped her, usually on second and third shifts. A grievance submitted by the resident documented that she was not put to bed until after 11:00, that she called the nursing station three times, and ultimately had to go into the hall to yell for help. A third cognitively intact resident with cancer, diabetes, cerebral palsy, and dependence on staff for all ADLs except eating had a care plan requiring staff assistance for bed mobility, toileting, and transfers with a mechanical lift. During a continuous observation, this resident’s call light remained activated for 25 minutes before staff responded. During that time, the call light alarm sounded continuously while an RN, the DON, and the Human Resources Coordinator walked past the room multiple times without checking on the resident, and the RN and DON entered another resident’s room without addressing the active call light. The resident later reported that the longest she had waited for a call light response was 3 hours, that many staff had quit, and that she had to wait for someone to answer her call light 3 to 4 times a week, usually for 2 to 3 hours. A fourth resident with mild cognitive impairment (BIMS 12) and dependence on staff for nearly all ADLs activated his call light and was observed waiting 31 minutes before staff entered the room and turned off the call light. During this period, the call light remained on continuously with no staff response until two CNAs finally entered the room. Additional staff interviews revealed inconsistent expectations and practices regarding call light response times. One LPN stated staff were expected to answer call lights within 15 minutes and felt there were enough CNAs but that nurses needed more help. A CNA stated that any staff member could answer a call light but acknowledged that not everyone did, and reported that some residents complained that aides would come in, turn off the call light, say they would return, and then not come back. The facility’s written policy on call lights required all staff who see or hear an activated call light to respond, to listen to the resident’s request, and to notify appropriate personnel if they could not meet the need, but the observed and reported events showed that these procedures were not consistently followed. The DON stated she expected staff to answer call lights within 2 minutes and that any staff member should respond and check on a resident with an active call light rather than walk by. She acknowledged that residents, including those described above, had complained to her about untimely call light responses and about being left up later than desired despite having their call lights on for extended periods. The facility’s own policy outlined a process for responding to call lights, including not promising something staff could not deliver and staying with the resident if assistance was needed, but the documented observations, resident and family reports, and staff interviews demonstrated repeated delays and failures to respond promptly to call lights for multiple dependent residents.
Failure to Honor Resident Dignity and Self-Determination During Personal Care and Smoking Restrictions
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, respect, and self-determination for two cognitively intact residents. Resident #6, who had cellulitis, lymphedema, and dependence on staff for transfers, showers, and personal hygiene, had a care plan directing staff to wash her hips gently with soap and water and not to scrub. During bathing on 4/17/26, Resident #6 reported that a CNA (Staff E) scrubbed her right hip roughly despite the resident asking her to be gentler and to stop. The resident stated the scrubbing was so hard that the area began to bleed and described the aide as "not nice" while scrubbing roughly. Staff interviews corroborated that Resident #6 expressed discomfort and asked for the rough washing to stop. Staff F, a CNA who assisted with the bath, reported that Resident #6 said Staff E was rubbing her belly too hard and asked her to stop. Another CNA, Staff B, stated that Resident #6 complained that Staff E rubbed too hard during the wash, causing her sides to bleed, and that he reported this complaint to the Administrator. Staff E acknowledged bathing Resident #6 and washing an open area beneath her abdomen, recalled the resident saying it hurt, and stated she considered this normal for the resident; she could not recall whether the resident asked her to stop rubbing so hard. The deficiency also includes an incident involving Resident #3, who had intact cognition, alcoholic polyneuropathy, generalized muscle weakness, and unsteadiness on his feet. The facility had a non-smoking campus policy documented in progress and social services notes, and Resident #3 was repeatedly informed that smoking was not allowed on facility grounds. Resident #3 reported that he did not understand why other residents and staff were allowed to smoke while he was told he could not, and that he was not told where he could smoke. He stated that when he was outside with a visitor holding an unlit cigar and planning to leave the property to smoke, the Social Worker took his cigar away and attempted to take the visitor’s cigarettes, which the visitor refused. The Social Worker later stated she took the resident’s cigar because the Administrator told her to, and the DON reported she could not explain why the Social Worker took the cigar and that no smoking assessment had been completed for this resident.
Failure to Assess and Authorize Self-Administration of Nebulizer Treatment
Penalty
Summary
The deficiency involves the facility’s failure to assess and authorize a resident for self-administration of a prescribed nebulized medication despite repeated observations of the resident using the nebulizer without staff present. The resident had a physician’s order for DuoNeb via nebulizer four times daily at scheduled times and had a BIMS score of 12/15, indicating mild cognitive impairment, with diagnoses including anxiety, depression, asthma, history of stroke, drug use, and metabolic encephalopathy. The MDS indicated the resident was dependent on staff for all ADLs except needing substantial/maximal assistance for eating, and the care plan documented impaired cognitive function and the need for cueing, orientation, supervision, and task segmentation. The care plan also included a problem area for infection risk with an intervention to administer treatments as ordered. Surveyors observed multiple instances where the nebulizer treatment was running without appropriate staff administration or supervision. On one occasion, the nebulizer machine was on with DuoNeb solution in the chamber and mist exiting the face mask, which was lying on the bed while the resident lay flat, with no staff present. On another observation, the resident was in bed holding the nebulizer mask about 20 inches from his mouth with the machine running, and later the mask was on the floor with the machine still on, again with no staff present. A further observation showed the resident in bed with the nebulizer mask on his face and no staff present. A nurse stated she had to go back to check on the resident because he had a history of taking the nebulizer mask off during treatment. Review of the clinical record showed no self-medication administration assessment, no care plan direction addressing self-administration of the DuoNeb nebulizer treatment, and no physician order authorizing self-administration, despite facility policy requiring an interdisciplinary assessment and documentation before allowing self-administration of medications.
Incomplete investigation of resident abuse allegation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of abuse made by a cognitively intact resident. The resident, who had a history of CVA, aphasia, hemiplegia, anxiety, and depression, required substantial/maximal assistance with ADLs and one-person assist for toileting and stand-pivot transfers. In the early morning hours, the resident contacted her family, reporting that a CNA had yelled at her, called her names such as “stupid,” taken her soda and poured it out, and pushed her in the chest/shoulder area. When staff entered the room after a call from the family, they found the resident extremely upset, using a communication board and gestures to indicate that she had been yelled at, pushed, and that there should have been two staff present instead of one. Nursing staff, including an RN and an LPN, assessed the resident and performed a head-to-toe skin assessment, finding no bruises, redness, or other signs of physical injury. The CNA identified as involved reported that she had responded to the call light, told the resident she had just been changed, and then changed her again. The CNA stated that when the resident stood up barefoot, she began to slip, and the CNA held her at the waist to prevent a fall; the CNA denied touching the resident above the waist and described the resident as sometimes “plopping” herself into the chair. Other CNAs confirmed that the resident sometimes plopped herself down into her chair during care. The resident, however, continued to report that she had been yelled at, called names, and pushed, and she became visibly distraught when recounting the incident to surveyors. The facility’s own abuse policy required the Administrator to document allegations, collect supporting documents, and attempt to obtain witness statements from all known witnesses, as well as to encourage reporting without fear of recrimination. The Administrator stated she followed a checklist, spoke to staff and residents, and interviewed residents on the same hall, but she did not obtain written statements from staff and denied the State Agency access to her investigative file. The Administrator later provided only a list of three staff interviewed (the involved CNA, an RN, and an LPN) and eight residents identified as interviewable, all on the same hall. However, the March staffing assignment showed that five staff (three CNAs, one RN, and one LPN) worked the relevant night shift, and two additional CNAs from that shift reported they were never interviewed about the allegation. Furthermore, during State Agency interviews, three of the eight residents the Administrator claimed to have interviewed denied having been asked by facility staff about concerns regarding rough or abusive treatment. These omissions demonstrate that the facility did not interview all staff on duty or all potentially relevant residents on the hallway, and did not fully follow its own abuse investigation protocol, resulting in an incomplete investigation of the abuse allegation. Additional information from facility staff further underscored the seriousness of the resident’s report and the need for a comprehensive investigation that did not occur. The RN and LPN who assessed the resident both stated they had never seen her that upset before and described her as looking toward the door as if afraid. The social worker reported that the resident said she had been physically hurt and that her feelings were hurt by a staff member’s actions, and described the resident as tearful when discussing the incident. Despite these consistent accounts of significant distress and specific allegations of verbal and physical mistreatment, the facility’s investigative steps were limited to a small subset of staff and residents, without documented witness statements from all known staff on duty and without confirmation that all cognitively able residents on the hall were interviewed about possible concerns with staff treatment. This incomplete process failed to meet the facility’s own policy requirements for investigation of alleged abuse. The facility’s abuse policy defined abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including verbal and mental abuse. The resident’s reports of being yelled at, cursed at, called “stupid,” and pushed, along with her visible distress and the corroborating description of her emotional state by family and staff, fell within the type of allegation that required a thorough investigation under this policy. Nonetheless, the Administrator’s investigative file, as described, lacked comprehensive staff interviews, lacked written witness statements, and did not align with the policy directive to obtain statements from all known witnesses and to fully identify and investigate potential abuse. These documented gaps in the investigative process constitute the core deficiency identified by surveyors.
Failure to Implement and Follow Up on Specialty Referral Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow up on hospital discharge recommendations and clinic orders for specialty evaluations for one cognitively intact resident. After a hospitalization in August 2025, the resident was discharged with recommendations to be evaluated by a rheumatologist and a podiatrist. The resident’s diagnoses included alcoholic polyneuropathy, generalized muscle weakness, and unsteadiness on feet, and hospital documentation noted diffuse psoriasis, hand arthritis, and psoriasis as active problems. Subsequent geriatric clinic notes in November 2025 documented a rheumatology referral with the date pending and an order for podiatry to see the patient. Despite these documented needs and orders, the resident reported after more than seven months in the facility that he had not yet seen either a rheumatologist or a podiatrist and described itchy, raised, dark pink areas covering up to 50% of each arm. Interviews with facility leadership confirmed delays and lapses in arranging the ordered specialty care. The Administrator stated that a rheumatology referral was ordered at admission but acknowledged that the facility did not attempt to make the rheumatology referral until January 2026, approximately five months after admission, citing issues related to Medicaid coverage and other pressing matters causing the process to be “lost.” Regarding podiatry, the Administrator reported that the resident had been scheduled to see a podiatrist in early January 2026 but was not seen because Medicaid was not approved at that time, and a rescheduled appointment in March 2026 did not occur for reasons the Administrator could not explain. The DON stated she expected staff to follow physician orders and, for podiatry referrals, to place the resident on the podiatrist’s list for the next visit unless an urgent referral was needed, indicating that these expectations were not met in this case.
Failure to Ensure Timely Dialysis and Complete Pre/Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident who required hemodialysis consistently attended dialysis on time and received thorough pre- and post-dialysis assessments as ordered. The resident had renal insufficiency requiring dialysis, diabetes mellitus, paraplegia, and intact cognition, and was scheduled for dialysis on Monday, Wednesday, and Friday with a pick-up time of 9:30 AM. Review of the clinical record and MAR showed that required pre- and post-dialysis assessments were not fully completed on multiple dates, including missing documentation for thrill, bruit, access site condition, cognition, and weight, with no explanations in the record for these omissions. The facility’s hemodialysis policy required ongoing assessment and monitoring for complications before and after treatments, but the documentation did not reflect that these assessments were consistently performed. The resident reported being late to dialysis once or twice a week, stating she was supposed to be in the dialysis chair by 10:00 AM but often did not arrive until 10:30 AM, and that the dialysis center expected her to arrive by 9:30 AM to start on time. A dialysis provider staff member stated the resident had missed transportation to an appointment because she was not ready on time. The DON stated she expected residents with a 9:30 AM dialysis time to be up and ready by 8:00 AM and ready for pick-up by 8:45 AM, and that she did not know how many times this resident had been late. Staff interviews indicated that post-dialysis assessments should include vital signs, weight, and evaluation of the fistula site for thrill, bruit, appearance, and dressings, but the MAR review showed these elements were frequently incomplete, contributing to the identified deficiency in dialysis-related care and services.
Improper Storage and Undocumented Disposition of Discontinued Medications
Penalty
Summary
The deficiency involves the facility’s failure to properly dispose of or return discontinued, unused, or leftover medications following resident death, discharge, or changes in medication regimens. Surveyors found that for three residents, the facility could not provide documentation that medications were either destroyed or returned to the pharmacy as required by policy. The facility’s own self-reported incident indicated that an anonymous complaint to the corporate compliance office alleged theft of resident medications, and the subsequent internal investigation identified concerns with how discontinued medications were handled and stored. The facility had recently changed from one pharmacy provider to another, and medications were supplied both via an automated dispensing system and blister-pack cards, with narcotics stored under double lock in medication carts and other medications in a locked medication room. Interviews with multiple staff revealed that discontinued medications, including narcotics, were routinely stored in the DON’s office rather than being promptly destroyed or returned. The former ADON reported that when residents were discharged or had medication changes, the former DON placed these medications in an unlocked cupboard in her office, a practice that had been ongoing for two to three years. She stated there had been at least 30 medications in that cupboard and that the former DON said they might as well keep them since they would not receive pharmacy credit. The ADON and other staff reported that the former DON gave medications from this cupboard to staff who did not have insurance and discussed helping a family member with these medications. Staff also reported that discontinued narcotics were kept in a locked drawer of the DON’s desk without any inventory or shift-to-shift count, and that only the DON had the key until the HR Manager accessed the desk during the DON’s vacation and found multiple medications, including narcotics. The review of clinical records and pharmacy documentation for specific residents showed missing evidence of proper medication disposition. One resident who was admitted and later died at the facility had multiple medications dispensed in blister-pack form by both pharmacies, including atorvastatin, pantoprazole, warfarin, bumetanide, carvedilol, and hydroxyzine; the facility could not produce documentation of destruction or pharmacy invoices showing return of these medications after the resident’s death. Another resident who was admitted and later discharged had lidocaine 5% patches dispensed, but the facility could not provide documentation of destruction or return after discharge. A third resident, admitted and later discharged home, had several medications dispensed by the second pharmacy (bumetanide, glipizide, lisinopril, apixaban, and oxybutynin), and the facility could not provide pharmacy invoices documenting their return. Interviews with pharmacy representatives clarified that, contrary to some staff beliefs, blister-pack medications could be returned for credit under certain conditions, and facility policies required that discontinued medications be removed from active use, stored in a separate locked area, and either returned or destroyed with appropriate documentation and witnesses. These findings collectively demonstrate that the facility did not follow its own policies and applicable standards for the secure storage and disposition of discontinued and leftover medications. Additional staff interviews further detailed the inconsistent and improper handling of discontinued medications. One LPN stated that there was a tote in the medication room where discontinued medications were placed and that, because the pharmacy often refused returns, nurses used a Drug Buster system to destroy them. However, other staff consistently described the presence of approximately 20–30 discontinued medications in the DON’s office cupboard and narcotics in the DON’s desk drawer. The HR Manager confirmed that, during the DON’s vacation, he unlocked her desk to retrieve personnel paperwork and observed at least 20 different medications in the drawer, and he reported this to the Administrator. The Administrator acknowledged that the corporate investigation confirmed medications were stored inappropriately in an unlocked cupboard in the DON’s office and that the DON had given a CNA one of these medications, which the CNA later returned during the investigation. The Administrator also stated that narcotics found in the DON’s desk included a blister-pack card and a used bottle of liquid morphine with an unknown remaining amount, and that it was not appropriate for the DON to keep narcotics in her desk. Facility policies in effect required all drugs and biologicals to be stored in locked compartments, controlled substances to be secured under double lock, discontinued medications to be removed from active use and stored in a separate locked area, and all destruction or return of medications to be documented with appropriate witnesses, which did not occur in these instances. Pharmacy representatives provided additional context that contrasted with staff practices and beliefs. A nurse consultant from the second pharmacy stated that medications should be returned to the pharmacy when discontinued or when a resident is discharged, except for narcotics, topicals, inhalers, accessed vials, or other non-returnable items, and that returns had to occur within a specified time frame to receive credit. A representative from the first pharmacy stated that the state was a no-return state for credit, while another LTC pharmacist consultant clarified that facilities could return blister-pack medications for credit even if some doses had been used, as long as the remaining doses were sealed and intact, and that this was common practice in the state. These statements, combined with the facility’s inability to produce destruction logs or return invoices for the medications associated with the three residents, and the documented storage of discontinued medications and narcotics in the DON’s office and desk, form the basis of the deficiency related to failure to complete proper disposition of medications in accordance with policy and regulation.
Failure to Provide Adequate Discharge Planning and Education for Resident Leaving AMA
Penalty
Summary
The facility failed to ensure that a resident was adequately educated on potential discharge options and prepared for a safe transfer/discharge after the resident signed an Against Medical Advice (AMA) form. The resident, who was cognitively intact and had multiple medical diagnoses including heart failure, neurogenic bladder, diabetes mellitus, and persistent mood disorders, required assistance with several activities of daily living and was on a complex medication regimen. Despite these needs, there was no documentation that alternative discharge plans were discussed with the resident on the day of discharge, nor was there evidence that the resident was provided with sufficient information or support to ensure a safe transition. The incident began after an altercation between the resident and another resident, which resulted in both being sent to the hospital for evaluation. Upon return, the resident was presented with the AMA paperwork by the Business Office Manager (BOM) and Director of Nursing (DON), which he signed. Interviews revealed that the resident did not fully understand the AMA form and felt pressured to leave due to concerns about the incident and possible police involvement. Staff interviews confirmed that the resident needed facility-level care for his mental health and diabetes management, and that he was not offered other suitable discharge alternatives within the next 30 days. The resident ultimately left the facility for a homeless shelter, arranged by the social worker, without his medications and without a clear plan for ongoing care. He subsequently experienced a significant health issue related to his diabetes and required hospitalization. The facility did not have a policy regarding discharge against medical advice, and staff acknowledged that no comprehensive discharge planning or education was provided to the resident prior to his departure.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to provide adequate bathing and showering services to four residents, as per their care plans and preferences. Resident #2, who has intact cognition and requires substantial staff support for bathing, reported not being offered a bath or shower for over a week after refusing one due to feeling unwell. The facility's Shower Book lacked documentation of any completed showers or baths for this resident after the refusal. Resident #3, also with intact cognition and requiring moderate staff support, preferred weekly showers but reported not receiving one for five weeks until she mentioned it to therapy staff. The facility's Shower Book did not document any showers or baths for this resident, indicating a lack of adherence to her care plan. Resident #4, who requires substantial staff support, could not recall the last time he had a bath or shower, noting it was before his recent hospitalization. The facility's Shower Book confirmed no documentation of showers or baths since his return. Resident #5, who prefers bed baths twice weekly, reported inconsistencies in receiving them, with the last documented bed bath occurring on a different day than scheduled. The Assistant Director of Nursing acknowledged the issue and implemented changes to the staff assignment sheet to address the deficiency.
Deficiency in Shower Room Maintenance
Penalty
Summary
The facility failed to maintain three shower rooms in a functional and sanitary manner, as observed during a survey. The East Hall Shower Room had missing floor tiles and dirty grout, with a thick black residue along the floor and wall junctions. Staff A, a CNA, mentioned that the tiles had been missing for several months, and she believed the Housekeeping Department was responsible for cleaning the shower rooms. The Interim Administrator was unaware of the missing floor tiles and the condition of the grout and residue buildup. The [NAME] Hall Shower Room was observed to have a dark gray residue buildup on the grout between the tiles, with dirty caulk and orange calcium buildup along the floor and wall junctions. The discoloration and buildup extended up to eight inches high on the walls. The Interim Administrator stated she thought Housekeeping cleaned the tile floors but would check with Maintenance Staff regarding the grout cleaning responsibilities. The North Hall Shower Room had dirty grout with black residue buildup, missing wall tiles, and exposed crumbling structure. The black residue was present on the floor and walls, with several tiles not attached to the wall. The Interim Administrator mentioned that repairs were prioritized after the initial observation, but the report does not detail any corrective actions taken before the survey. The facility's policy on maintaining a safe and homelike environment was not adhered to, as evidenced by the unsanitary conditions in the shower rooms.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights within the expected timeframe, leading to a deficiency in meeting resident needs. Resident #2, who has intact cognition and requires substantial staff assistance for daily activities, reported that staff response times to call lights were typically 45 minutes or longer. This delay in response was consistent regardless of the time of day or week, indicating a systemic issue in addressing resident needs promptly. Additionally, an observation on a specific day revealed that Resident #9's call light remained activated for over 30 minutes without a response from staff, despite multiple staff members being present at the Nurses Station. Resident #9, who has mild cognitive impairment and requires assistance for transfers and toileting, activated the call light but did not receive timely assistance. The delay was attributed to the assigned CNA being on break, and other staff members did not respond to the call light promptly. The Director of Nursing and Interim Administrator acknowledged that any available staff should answer call lights, but this expectation was not met during the observed period.
Failure to Monitor Resident's Condition Before and After Dialysis
Penalty
Summary
The facility failed to provide ongoing assessments and monitoring of a resident's condition before and after dialysis treatments. The resident, who has intact cognition and is diagnosed with renal insufficiency, renal failure, and end-stage renal disease, receives hemodialysis three times a week. The care plan for the resident did not include specific interventions for staff to assess the resident's condition before and after dialysis treatments. Although the resident reported that a nurse assesses her condition before leaving for dialysis, the facility's documentation practices were inconsistent. Interviews with staff revealed that while training on port care and documentation is provided, the facility did not consistently document assessments after the resident returned from dialysis. The Director of Nursing confirmed that no assessment of the resident's condition is completed upon return from dialysis services. A review of the nurse progress notes showed only one entry related to post-dialysis assessment in the previous month, and the facility's dialysis communication and transfer documentation failed to include an assessment upon the resident's return.
Inadequate Nail Care for Resident with Memory Impairment
Penalty
Summary
The facility failed to provide adequate nail care for a resident with memory impairment and moderate decision-making impairment, who required substantial to maximum staff assistance for bathing and hygiene. The resident, diagnosed with non-Alzheimer's dementia and anxiety disorder, was observed with long, thick, and yellow toenails curling over the toes. The resident's family reported having requested nail care at least twice since the resident's admission, but no action had been taken. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were responsible for cutting toenails unless the resident was diabetic, in which case nurses were responsible. The Director of Nursing (DON) mentioned that the facility's podiatrist had retired, and a new contract was being arranged, resulting in a lack of podiatrist visits since March or April. The facility's policy on Activities of Daily Living Care Bathing did not address toenail care, contributing to the oversight.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to follow a physician's order to ensure a resident ate meals in a safe manner. Resident #38, who has intact cognition and a history of cerebrovascular accident, seizure disorder, and dysphagia, was observed eating meals in her room without supervision, contrary to the physician's order that required her to eat upright in the dining room under supervision. The resident's care plan indicated a need for a mechanically altered diet due to dysphagia and required monitoring for signs of swallowing difficulties, but it did not specify supervision requirements when eating in her room. Observations revealed that Resident #38 was left unsupervised while eating in her room on multiple occasions. Staff interviews confirmed that the resident was on isolation due to MRSA in her sputum and was eating in her room, but staff were supposed to stay with her during meals. However, the resident reported that staff did not remain in the room while she ate, and observations corroborated this, showing no staff present during meal times in her room.
Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain proper catheter care for a resident identified as Resident #18, who was cognitively intact and dependent on staff for various activities. Observations revealed that the resident's Foley catheter bag and tubing were frequently found touching the floor, both in the resident's room and in common areas such as the dining room and hallway. Despite the facility's policy on catheter care, which did not specifically address keeping the catheter bag and tubing off the floor, staff interviews confirmed that the expectation was to keep the catheter bag below the waist, covered for dignity, and off the floor at all times. Additionally, the facility failed to provide adequate incontinent care for a resident identified as Resident #2, who had severe cognitive impairment and required substantial assistance for personal hygiene. During an observation, a CNA provided care without cleansing the perineal area, abdominal folds, or hips, despite the resident being incontinent. The CNA cited understaffing as a reason for inadequate care. Interviews with nursing staff, including the DON, indicated that the expectation was to thoroughly cleanse the perineal area and other affected areas using appropriate materials, as outlined in the facility's policy on incontinent care.
Failure to Prepare Pureed Food to Physician-Ordered Texture
Penalty
Summary
The facility failed to properly prepare pureed food according to physician-ordered texture for two residents on a pureed diet. During an observation, it was noted that the food served to these residents did not meet the required consistency. The pureed meat was observed to be thick and more like ground meat rather than smooth, as required. The Dietary Manager confirmed that the meat should have been smooth and the vegetables should have been like pudding. The State Agency intervened and requested the removal of the plates from the residents. The deficiency was further highlighted by staff interviews, where a Certified Nursing Assistant mentioned that several complaints had been made to the administrator about the kitchen, but no action had been taken. The facility's policy on pureed food guidelines, which directs staff to ensure food is prepared to a smooth consistency, was not followed. The residents involved had specific dietary orders due to their medical conditions, including dysphagia, which necessitated a pureed diet to ensure safe swallowing.
Repeated Deficiencies in Facility's QAPI and Staffing
Penalty
Summary
The facility failed to effectively correct deficiencies without repeated citation, as evidenced by the CMS CASPER reports. The deficiencies cited include F677 Activities of Daily Living in 2022 and 2023, F689 Free of Accident Hazards/Supervision/Devices in 2023, F690 Bowel/Bladder Incontinence, Catheter in 2023, F725 Sufficient Nursing Staff in 2020, 2022, and 2023, and F865 QAPI Program/Plan, Disclosure/Good Faith Attempt in 2023. These deficiencies were identified during the Recertification Survey with an exit date of August 15, 2024. During an interview, the Administrator explained that concerns are brought to the QA Committee through data from various sources, including input from employees, residents, families, audits, and grievances. This information is discussed in morning management meetings and referred to the QAPI committee when a problem is identified. The facility's QAPI Plan, dated August 20, 2020, outlines the purpose and procedures for quality assurance and performance improvement activities, but the repeated citations suggest that the measures taken were not effective in correcting the deficiencies.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received their ordered medications, resulting in a significant medication error. On the evening of June 3, 2024, a Certified Medication Aide (CMA) mistakenly delivered the wrong medications to a resident. The error occurred when the CMA, after completing his medication pass, assisted a Registered Nurse (RN) on another hall. The RN had set up medications for two residents in medication cups on the cart. The CMA, instructed by the RN, mistakenly took the wrong medication cup and administered it to the resident. Upon realizing the error, the RN notified the appropriate personnel, and the resident was sent to the emergency room for further evaluation. The resident, who had a history of hypertension, renal insufficiency, and a seizure disorder, experienced a significant change in condition due to the accidental overdose. The medications administered in error included Cefadroxil, L-Arginine, Trazodone, Tamsulosin, Baclofen, and Melatonin. The resident, who was on dialysis, developed acute encephalopathy and hypotension as a result of the overdose. In the emergency room, the resident became sedate, difficult to arouse, and required intubation to maintain her airway. She was subsequently admitted to the intensive care unit (ICU) for close monitoring and management. The incident highlighted the failure of the facility to adhere to medication administration protocols, specifically the requirement that the person who prepares the medication must be the one to administer it. The RN admitted to knowing that the CMA picked up the wrong medication cup but did not stop him. This oversight, combined with the lack of attention to detail, led to the resident receiving another resident's medications, resulting in a serious adverse event that required intensive medical intervention.
Failure to Provide Prescribed Physical Therapy Services
Penalty
Summary
The facility failed to provide rehabilitation services in accordance with physician orders for a resident. The clinical record review and staff interview revealed that the resident had a physician's order for a physical therapy evaluation and treatment, with a specified frequency of five times a week. However, the Physical Therapy Treatment Encounter Notes indicated that the resident received physical therapy services only once during two separate weeks in January and twice during a week in February. Despite the resident's progress noted by the Physical Therapy Assistant, the prescribed frequency of therapy sessions was not met, leading to a deficiency in the provision of specialized rehabilitative services as required by the physician's orders.
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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