Centerville Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerville, Iowa.
- Location
- 1208 East Cross Street, Centerville, Iowa 52544
- CMS Provider Number
- 165225
- Inspections on file
- 20
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Centerville Specialty Care during CMS and state inspections, most recent first.
The facility failed to ensure proper hand hygiene and glove changes during wound care for two residents with multiple open wounds and MASD. In one case, an RN removed soiled dressings from both lower legs without changing gloves between legs, repeatedly changed gloves without performing hand hygiene, and handled wound products after dropping a medication cup on the floor, then continued treatment without hand hygiene. In another case, an RN cleansed two open abdominal-fold wounds with the same washcloth and changed gloves without hand hygiene before applying Triad paste to both wounds with the same fingers. Staff interviews, including with an RN, an LPN, the IP, and the DON, confirmed that facility expectations and policy required hand hygiene between glove changes and glove changes between separate wounds to prevent cross-contamination.
The facility did not obtain or document informed consent for antipsychotic medications for two residents with impaired cognition. Although staff reportedly discussed the medications with family members, there was no documentation of completed consent forms outlining the risks and benefits prior to starting the medications, as required by facility policy.
Staff did not notify the provider or perform follow-up assessments after a resident with diabetes had multiple blood sugar readings above 500 mg/dl, despite care plan directives and facility policy requiring such actions.
A resident with severe cognitive impairment and a history of falls was assisted to the bathroom by a staff member without the use of a gait belt, contrary to facility policy and the resident's care plan. During the transfer, the staff member used one hand to adjust a commode and the other to support the resident, who then stepped backward and fell, resulting in reported pain. Interviews confirmed that the gait belt, which was typically used for this resident, was not utilized during this incident.
Staff did not weigh or measure ham portions before preparing mechanical soft and pureed diets, instead estimating serving sizes and using a standard scoop that did not meet the required 5-ounce portion per the menu. Additionally, rolls were not pureed and served as required for three residents on pureed diets. These actions resulted in multiple residents not receiving correct portions or all menu items as specified.
A staff member failed to remove PPE after providing care to a resident and transported the resident in a wheelchair with indwelling catheter tubing in contact with the floor. The resident had multiple medical conditions and was dependent for all ADLs. Facility policy required PPE removal before exiting the room and keeping catheter tubing off the floor, but these protocols were not followed.
The facility failed to maintain proper kitchen sanitation and food handling practices. Observations included the Dietary Manager's hair not fully restrained, outdated turkey, and dust on fire suppression spigots. The manager handled food without washing hands after picking up refuse. Dust and food particles were found on various surfaces, and the ice machine and dishwasher had buildups. The manager acknowledged staffing struggles and cleanliness expectations.
A facility failed to provide a resident on a pureed diet with the correct portion and texture of food. The Dietary Manager served a fish filet in a pureed form but did not provide the full portion, and processed green beans to a liquid consistency instead of the required pudding consistency. The facility's policy mandates that pureed food should be of pudding consistency and that residents should receive the same amount as others.
A resident with severe cognitive impairments and a history of wandering was not treated with dignity and respect by an LPN. The LPN used raised arms and voice to redirect the resident, escalating the situation. On another occasion, the LPN physically grabbed and pushed the resident, causing him to stumble. Housekeeping staff intervened to de-escalate the situation. The facility's policy prohibits such actions and emphasizes a culture of compassion.
The facility failed to properly assess and intervene for two residents, leading to deficiencies in care. A resident with a catheter had it removed without adequate follow-up, resulting in discomfort and the need for reinsertion. Another resident experienced an unwitnessed fall, but required neurological assessments were not documented, indicating a lapse in monitoring and care protocols.
Improper Hand Hygiene and Glove Use During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene and glove use during wound care, resulting in potential cross-contamination between wounds. For one resident with congestive heart failure, diabetes, peripheral vascular disease, and multiple venous ulcers, staff did not change gloves appropriately between wounds or perform hand hygiene between glove changes. This resident was cognitively intact but dependent on staff for most ADLs and had open venous ulcer wounds on both lower legs, as well as a left heel condition and a skin tear on the left shin, all requiring specific wound care orders including cleansing with Vashe Wound Cleanser, application of Triad paste, silver dressings, and Betadine. During an observed wound care session for this resident, an RN and an LPN initially washed their hands, gowned, and gloved, and a clean field was set up. The RN removed dressings from the right and then the left leg without changing gloves between legs, despite the right leg dressing having a large amount of bloody drainage and both legs having open wounds. After removing dressings from both legs, the RN changed gloves without performing hand hygiene, while the LPN removed gloves, washed hands, and re-gloved. The RN then cleansed the right leg wounds and later removed gloves, obtained Triad paste, re-gloved without hand hygiene, and applied Triad paste with gloved fingers. After both nurses removed gloves, washed hands, and re-gloved, the RN applied dressings to the right leg. When the medication cup with Triad paste was dropped on the floor, the RN picked it up, removed one glove, obtained more Triad paste, re-gloved again without hand hygiene, and applied Triad paste to the left leg, followed by Betadine to the left heel and additional dressing applications, again changing gloves without performing hand hygiene. For a second resident with diabetes, morbid obesity, MASD, and open wounds under an abdominal fold, the RN also failed to perform hand hygiene between glove changes. This resident was cognitively intact, dependent for most ADLs, and had an open MASD wound on the right iliac crest with orders for Triad paste and Interdry to abdominal folds. During observation, the RN placed Triad paste in a medication cup, washed hands, and gloved, then exposed the abdominal area and used a wet washcloth with a small amount of hand soap to wipe two open wounds on both sides of the abdominal fold, followed by drying with a hand towel. The RN then removed gloves and donned a new pair without performing hand hygiene between glove changes and applied Triad cream to both open wounds with the same fingers. Interviews with the RN, another RN, an LPN, the Infection Preventionist, and the DON confirmed that facility expectations and policy required hand hygiene between glove changes and glove changes between wounds to prevent cross-contamination, and the hand hygiene policy specified hand hygiene before handling clean or soiled dressings, after contact with blood or body fluids, after handling used dressings, and after removing gloves.
Failure to Document Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of antipsychotic medications for two residents. For one resident with diagnoses including anxiety, depression, and non-Alzheimer's dementia, and a severely impaired cognition score, the clinical record showed an order for Abilify was initiated. Although a nurse's note indicated that the resident's representative was spoken to about the medication's reason and benefits, there was no documentation of a completed medication consent form outlining the risks and benefits prior to starting the medication, as required by facility policy. Similarly, another resident with moderately impaired cognition and diagnoses including diabetes, heart failure, and coronary artery disease was started on Rexulti. The care plan noted the use of antidepressant medications, but again, there was no documentation of a completed medication consent form prior to the initiation of the medication. The DON confirmed that while staff had conversations with the residents' families regarding the medications, these discussions were not documented in the clinical notes.
Failure to Notify Provider and Assess After Critically High Blood Sugar Readings
Penalty
Summary
Facility staff failed to carry out required assessments and interventions after a resident experienced multiple episodes of significantly elevated blood sugar levels. The resident, who had diagnoses including diabetes, heart failure, and coronary artery disease, had care plan directives and physician orders specifying that staff should notify the provider if blood sugar readings exceeded 500 mg/dl. Despite this, clinical records showed that on several occasions, the resident's blood sugar readings were well above this threshold. Documentation revealed blood sugar readings of 547 mg/dl and 600 mg/dl on one day, and 538 mg/dl on another, without any evidence that the provider was notified or that follow-up assessments or monitoring were conducted. The facility's policy required staff to follow physician-ordered parameters for reporting high blood sugars, but there was no documentation to show these protocols were followed. Interviews with the DON confirmed that no additional documentation or provider notification could be found regarding these incidents.
Failure to Use Gait Belt During Resident Transfer Results in Fall
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions, specifically the use of a gait belt, for a resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, non-Alzheimer's dementia, and restless leg syndrome. The resident was assessed as dependent on staff for toilet transfers and required partial to moderate assistance for walking. According to the care plan, the resident was at risk for falls and required assistance from one to two staff members for walking and transfers. Despite these documented needs and facility policy requiring the use of gait belts for safe lifting and movement, a staff member assisted the resident without a gait belt during a transfer to the bathroom. During the incident, the staff member, who was a traveling nurse, asked other staff about the resident's assistance needs and was told the resident was an assist of one. While attempting to help the resident use a commode, the staff member used one hand to adjust the commode and the other to support the resident, who then stepped backward and fell. The resident later reported pain following the fall. Interviews confirmed that the gait belt was not used during this transfer, although it was typically used for this resident. The DON confirmed that staff should use a gait belt for residents requiring assistance of one or two for transfers.
Failure to Provide Correct Portions and Follow Menu for Modified Diets
Penalty
Summary
The facility failed to ensure that residents on mechanical soft and pureed diets received the correct portions and that the menu was followed as required. Observations revealed that staff did not weigh or measure the ham portions before processing them to mechanical soft and pureed consistencies. Instead, staff estimated the portion sizes and used a standard scoop size, which did not align with the menu requirement of a 5-ounce serving of ham for each resident. Additionally, staff did not provide rolls to residents on pureed diets as required by the menu, as they forgot to puree the rolls with the ham. Interviews with staff confirmed that the correct procedures for measuring and serving portions were not followed. The dietary manager stated that the process should involve measuring meat portions before processing and using a chart to determine serving size, but this was not done. The facility's policy also directed staff to ensure correct portions and to include all menu items, such as bread, in pureed diets. These failures resulted in five residents not receiving the correct portions and three residents not receiving all menu items as specified.
Failure to Remove PPE and Maintain Catheter Hygiene During Resident Transport
Penalty
Summary
Staff failed to implement the Infection Prevention and Control Program (IPCP) by not properly removing personal protective equipment (PPE) after providing resident care and by allowing indwelling catheter tubing to contact the floor during resident transport. Specifically, a physical therapy assistant was observed wearing PPE while assisting a resident in his room and then transporting him in a wheelchair to the shower room without removing the gown. During this transport, the resident’s indwelling catheter tubing was observed in contact with the floor. The staff member admitted to keeping the gown on because she anticipated needing it again for further care in the bathroom and was unaware that the catheter tubing had touched the floor. The resident involved had multiple diagnoses, including atrial fibrillation, heart failure, diabetes, thyroid disorder, arthritis, stroke, urinary tract infection, and acute cystitis with hematuria, and was dependent on staff for all activities of daily living and mobility. Facility policies required staff to remove PPE before exiting a resident’s room and to ensure catheter tubing and drainage bags were kept off the floor. Interviews with the infection preventionist and director of nursing confirmed that staff should have removed PPE before leaving the resident’s room, and policy review indicated that enhanced barrier precautions should be followed in certain situations outside the resident’s room, but not in hallways unless specific care activities were being performed.
Inadequate Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain adequate kitchen sanitation and food handling practices during two separate visits to the kitchen. During the initial kitchen tour, it was observed that the Dietary Manager's hair was not fully restrained under a hair net, and an opened package of turkey breasts was dated two weeks prior. Dust particles were hanging from the fire suppression system spigots. On a subsequent visit, the same dust was observed on the spigots, and the Dietary Manager was seen picking up refuse from the floor and then touching food without washing her hands. Additionally, the plastic menu holder, steam table, and a shelf above the steam table were found to be dusty and sticky, with loose food particles hanging over the food. Further observations revealed that the Dietary Manager retrieved ice cream from the freezer without washing her hands before serving meals. The ceiling above the sink was covered with dust-like particles, and a fire suppression system spigot above the spices and clean plates was covered with a thick layer of dust. The dishwasher had a crusty white buildup, and a drawer contained crumbs and a black substance in the corners. The ice machine had a brown buildup on the interior wall and a white buildup on the exterior. The Dietary Manager acknowledged the staffing struggles and the expectation for cleanliness, stating that all hair should be restrained under a hair net.
Deficiency in Pureed Diet Consistency and Portioning
Penalty
Summary
The facility failed to ensure that a resident on a pureed diet received the correct portion and texture of food. During an observation, the Dietary Manager (DM) processed a fish filet to a pureed consistency and served it to the resident, leaving 1/4 of a cup remaining, indicating the resident did not receive the full portion. Additionally, the DM processed green beans to a liquid consistency, which was not in accordance with the facility's policy that required pureed food to be of pudding consistency. The DM acknowledged that the resident should have received the entire fish filet and that the pureed food should not be runny. The facility's undated policy on Puree Technique directed staff to follow the menu as planned, process the correct number of portions, and ensure pureed food is of pudding consistency.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by interactions between a Licensed Practical Nurse (LPN) and a resident with severe cognitive impairments and a history of wandering and aggression. The resident, who had diagnoses including Non-Alzheimer's dementia and aphasia, was observed by housekeeping staff to be wandering the halls, a behavior noted in his care plan. On one occasion, the LPN attempted to redirect the resident by standing in front of him with raised arms and a raised voice, which escalated the situation. Despite an offer from a housekeeper to intervene, the LPN continued to interact with the resident in a manner that was not calm or respectful. Further incidents were reported where the LPN physically grabbed the resident by the arms to redirect him away from the front door and later from a room, actions that were described as aggressive. During one of these interactions, the resident began hitting the LPN, who then pushed the resident hard enough that he stumbled and almost fell, although the LPN prevented the fall. Housekeeping staff intervened by engaging the resident in an activity, which helped to de-escalate the situation. The facility's policy strictly prohibits abuse and emphasizes the importance of staff education and a culture of compassion, which was not adhered to in these interactions.
Deficiencies in Resident Monitoring and Care
Penalty
Summary
The facility failed to ensure appropriate assessment and intervention for two residents, leading to deficiencies in their care. Resident #5, who had an intact cognitive status and was dependent on maximal assistance for various needs, had a catheter removed on a trial basis. Despite the resident's preference to have it removed in the morning, there was a lack of documentation and follow-up by Staff E, an LPN, regarding the resident's voiding status. Although Staff E claimed the resident had voided a little, other staff and the resident's family reported no voiding occurred. This led to the reinsertion of the catheter by another nurse, which resulted in the return of 400 milliliters of urine, indicating a failure to monitor and address the resident's condition adequately. Resident #6, who was independent with some assistance and had a history of pneumonia, diabetes, and COPD, experienced an unwitnessed fall. The facility's protocol required frequent neurological assessments, including vital signs, which were not properly documented by Staff E and Staff F. Despite indications that vital signs were completed, there were no corresponding records in the PointClickCare system. This lack of documentation and adherence to protocol highlights a deficiency in the facility's monitoring and care practices for residents who have experienced falls.
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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