Chapters Living Of Council Bluffs
Inspection history, citations, penalties and survey trends for this long-term care facility in Council Bluffs, Iowa.
- Location
- 3000 Risen Son Blvd, Council Bluffs, Iowa 51503
- CMS Provider Number
- 165466
- Inspections on file
- 28
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 59 (1 serious)
Citation history
Health deficiencies cited at Chapters Living Of Council Bluffs during CMS and state inspections, most recent first.
The deficiency involves multiple failures in pressure ulcer prevention, assessment, and treatment for several residents. A resident admitted without ulcers developed an in-house Stage 2 sacral pressure injury that was not consistently measured or fully assessed for several weeks, despite documented infection and worsening appearance. Staff did not reliably notify the NP or MD of deterioration, did not change treatment orders in a timely manner, and did not update the care plan with new interventions, while the resident reported not being repositioned every 2 hours and sometimes remaining in a saturated brief overnight. Another resident with incontinence-associated dermatitis and documented skin risk had wound assessments with missing or inconsistent measurements, photos showing apparent Stage 2 sacral/coccygeal ulcers that were not documented as such, and a care plan that did not reflect the specific skin issues or interventions identified on the MDS. Staff interviews and the DON’s statements confirmed gaps in CNA reporting, nurse assessment, physician notification, and overall wound care practices.
Surveyors found that the facility failed to consistently involve residents and their representatives in interdisciplinary care plan conferences and did not keep care plans current with residents’ changing clinical conditions. Several residents and families reported they had not been invited to care conferences since a change in ownership, and the social services director acknowledged many conferences were not completed or documented. Care plans for multiple residents were not revised to reflect new transfer requirements (e.g., need for a full-body mechanical lift), new or discontinued indwelling catheters, new diagnoses such as influenza requiring EBP and droplet precautions, and the development or progression of pressure injuries, including MASD, DTI, Stage 2 ulcers, and a surgically debrided Stage 4 sacral ulcer with a wound vac. Staff interviews showed that the MDS coordinator was largely responsible for care plan updates, floor nurses generally did not revise care plans, and IDT participation and documentation of care conferences were inconsistent, resulting in outdated or incomplete care plans that did not match current orders or resident needs.
The facility failed to provide ongoing, understandable education on Resident Rights to its residents and/or their representatives. During a Resident Council meeting, residents reported they were unaware of having rights, did not know what those rights were, and did not know if they were posted in the facility. Review of several months of Resident Council minutes showed that leadership attended but did not provide Resident Rights education. The Life Enrichment Director acknowledged that staff had not been reviewing or educating residents on their rights during these meetings, and the DON stated that Resident Rights were only given at admission and not reviewed on an ongoing basis. Neither could confirm that Resident Rights were posted and readily available, despite facility policy requiring that residents be informed of their rights and that these rights be posted throughout the facility.
Surveyors found that multiple residents who required staff assistance with oral hygiene, toileting, and repositioning did not consistently receive this care and that it was not documented as required. Several residents with cognitive impairment or physical limitations, including those with multiple sclerosis, had care plans specifying staff assistance with oral care, yet their records contained no oral care documentation, and one resident’s room lacked oral care supplies. Residents and family members reported that oral care was rarely provided, that a resident often had food on her face and mouth, and that one resident had to use an alarm to prompt staff to reposition her and reported not being changed overnight despite urinary incontinence. Staff interviews confirmed that oral care was expected twice daily per facility policy, but also revealed frequent findings of residents with unclean faces and hands after meals.
A facility failed to prevent accidents and injuries by allowing a resident with moderate cognitive deficit to be pushed a long distance in a manual w/c without footrests while observed by nursing staff, and another resident with severe cognitive impairment to be pushed with feet dragging on the floor. Two dependent residents who required full body mechanical lifts reported or were described as being transferred either with only one staff or without the lift at all, with multiple CNAs and nurses acknowledging that single-staff lift transfers occurred despite the expectation for two-person assistance. Additionally, monthly hot water temperature logs showed elevated readings in some areas and stopped being recorded, while the plant operations director, DON, and administrator each admitted they did not know the appropriate temperature parameters for resident use and had no policies in place for water temperature, mechanical lift use, or wheelchair transport safety.
Two residents did not receive appropriate assessment and care according to orders and clinical needs. One resident with intact cognition had a diabetic ulcer on a toe that was present on admission but was not identified on the admission skin assessment, and no wound assessment, physician notification, or treatment occurred for about a week until an RN documented and initiated ordered care. Another resident with near-intact cognition had a head injury first seen as a red mark on the forehead; the LPN obtained vitals but did not initiate neuro checks, fully assess for additional injuries, or promptly notify the DON, physician, or family. Neuro assessments and provider notification were delayed until the area became a hematoma later in the day, and additional bruising on the hip and shoulder was only discovered after transfer to the ED.
Surveyors found that the facility failed to follow physician orders for medication administration, including not administering prescribed medications, giving medications outside of ordered parameters, and not documenting required monitoring. In several cases, staff did not notify the primary care provider when a resident refused multiple medications over several days, and medications were administered or withheld without proper documentation or physician approval.
Three residents with indwelling catheters did not receive catheter care and monitoring as required, with multiple missed entries for catheter output and failure to report changes in eating patterns that could indicate UTI. One resident was hospitalized with severe sepsis due to UTI, and another was admitted for a complicated UTI. Nursing staff and leadership confirmed that missing documentation meant care was not completed, and facility policy required regular documentation and reporting of unusual findings.
Surveyors found that staff did not consistently follow Enhanced Barrier Precautions or perform required hand hygiene during high-contact care activities for two residents with indwelling catheters and wounds. Staff failed to wear gowns during transfers and grooming, and did not always perform hand hygiene between glove changes, despite facility policy and posted instructions.
The facility did not consistently update care plans with new fall prevention interventions after residents experienced multiple falls, and failed to complete or document required neurological assessments following unwitnessed falls. Several residents with cognitive impairment and fall risk were affected, and staff interviews revealed inconsistent practices and lack of access to current policies.
The facility did not update its Facility Assessment after a change in ownership, continuing to use an outdated document with the previous facility name. The current Administrator confirmed no updated assessment had been completed, and the ADON was unable to access or locate relevant policies. Corporate staff did not provide requested policy information after being contacted.
The facility did not employ a qualified Infection Preventionist (IP) as required, with the designated IP and DON both still in the process of completing necessary training. The antibiotic stewardship program was not current, and staff were unclear about the IP's qualifications. Corporate support was limited to remote assistance, and updated policies from new ownership were not provided when requested.
Surveyors found that the facility did not maintain a clean environment, with dead insects remaining in a hallway for several days and a resident's room and bathroom left uncleaned despite family concerns. Housekeeping was expected to clean daily, but debris and stains persisted, and staff denied receiving complaints about cleanliness.
A resident who required significant assistance and had multiple medical conditions reported that a CNA was rude, spilled a bedpan on her bed, and placed her call light out of reach. The DON investigated internally and educated the CNA, but did not report the allegation to the State Agency as required. The previous administrator and other staff were not fully informed, and the facility could not provide a relevant abuse reporting policy during the survey.
Two residents reported staff misconduct, including rudeness, removal of call lights, and rough handling, but the facility failed to conduct thorough investigations. Key staff and resident interviews were not completed, written statements were not collected, and there was no evidence of a standardized process for investigating abuse allegations.
Two residents admitted with existing pressure ulcers did not have comprehensive care plans specifying the type and location of their wounds, and one resident's care plan lacked interventions to prevent new pressure ulcers. Staff interviews confirmed reliance on care plans for pressure ulcer management, but the plans were incomplete and lacked individualized interventions. The facility also lacked clear policies on care plan development and updating.
Care plans were not updated for three residents after they experienced falls, and one resident's care plan was not revised when a new pressure ulcer developed. The care plans lacked specific details and interventions, and staff interviews revealed confusion about responsibilities and procedures for care plan updates. The facility could not provide a policy on care plan revision, and corporate staff did not supply requested policies.
Two residents with pressure ulcers did not have their treatment orders consistently signed out as completed, with multiple omissions in documentation of wound care, dressing changes, and evaluations. Staff confirmed that unsigned orders on the TAR indicated treatments were not done, and the facility lacked a clear policy for treatment order administration and documentation.
The facility did not provide enough nursing staff to meet resident needs, resulting in delayed assistance for residents, including one who waited up to 40 minutes for help while managing a UTI. Staff reported operating mechanical lifts alone due to low staffing, and the facility lacked clear policies on call light response and lift use.
The facility did not maintain complete and accurate medical records for three residents, including missing documentation of scheduled showers and absent incident reports for two falls. Staff interviews revealed problems with access to the electronic charting system and a lack of clear documentation policies following a change in facility ownership.
The facility failed to maintain proper infection control during food preparation. The Culinary Supervisor used gloves while preparing grilled cheese sandwiches but touched non-food contact surfaces before handling food, violating the facility's policy. The Dietary Manager noted that staff were advised to avoid using gloves unless necessary to prevent complacency.
The facility failed to ensure that a CNA completed the required Dependent Adult Mandatory Reporter (DAMR) Training, as their training certificate had expired. This was discovered during a personnel file review, revealing non-compliance with the facility's policy that mandates periodic training to recognize and prevent abuse, neglect, and misappropriation of resident property.
The facility failed to implement proper infection prevention practices for two residents under Enhanced Barrier Precautions. A resident with an indwelling catheter received care from a CNA who improperly wore a gown, while another resident with a lung infection was not provided with necessary droplet precaution signage and PPE. Staff did not adhere to required PPE protocols, leading to deficiencies in infection control.
A facility inaccurately assessed a resident's MDS by documenting insulin use, despite the resident receiving Trulicity, not insulin. Staff interviews revealed a misunderstanding of Trulicity as insulin. The DON and Administrator acknowledged the error and the lack of a specific policy on MDS accuracy.
Two residents reported feeling disrespected by a CNA during personal care, with one resident having moderate cognitive impairment and the other having no cognitive impairment. The incidents were not reported to management, indicating a breakdown in the reporting process. The facility's policy prohibits such behavior, but the incidents were not investigated as required.
The facility failed to meet professional standards of care for two residents, leading to deficiencies in documentation and medication management. A resident with diabetes had a low blood glucose reading that was not documented or followed up as per policy. Another resident with hypertension received medication despite consistently low blood pressure readings, due to a lack of established parameters. Staff interviews revealed inconsistencies in handling these situations, and the facility lacked specific policies to guide care.
A resident was discharged to a hotel without securing home health services or follow-up appointments, despite having a history of orthostatic hypotension, type 2 diabetes, and chronic kidney disease. The social worker faced challenges with insurance acceptance and communication, leading to a delay in home health services and lack of follow-up appointments. The facility's discharge plan lacked documentation of arranged follow-up care, resulting in a deficiency in discharge planning.
A resident with a fracture experienced severe pain that was not adequately assessed or managed by the facility staff. Despite a care plan directing the administration of pain medications and physician notification if interventions were unsuccessful, the resident did not receive PRN pain medication on a critical day, and there was a lack of pain assessments and vital signs documentation. The resident's pain was later documented at a level of 9, leading to a transfer to the emergency department due to uncontrolled pain. Staff interviews revealed inconsistencies in pain management practices.
Failure to Prevent, Assess, and Manage Pressure Ulcers and Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention, assessment, and treatment, and to prevent the development and worsening of pressure ulcers for multiple residents, most extensively documented for Resident #29. Resident #29 was admitted without pressure ulcers and initially assessed with a Braden score of 20 (not at risk), later decreasing to 16 (at risk) and then to 9 (very high risk). An in-house acquired Stage 2 sacral pressure ulcer was first documented on 11/28/25 with measurements, and again on 12/6/25 with increased size. On 12/16/25, the wound was documented as a Stage 2 ulcer but without any measurements. From 12/16/25 through 1/3/26, there were no complete wound assessments with measurements, descriptions, or photos, despite ongoing skin check entries that noted a pressure injury on the coccyx/sacrum without measurements or detailed description. During this period, the care plan did not reflect new or updated interventions in response to the in-house acquired Stage 2 ulcer or its deterioration. Resident #29’s wound worsened significantly without timely or adequately documented provider notification or changes in treatment. Infection documentation from 1/1/26 through 1/5/26 noted a sacral ulcer infection with odor but lacked measurements, wound description, and MD notification. On 1/3/26, an unstageable sacral pressure ulcer with slough/eschar, strong odor, and a much larger area was documented. A subsequent 1/5/26 skin and wound evaluation described an unstageable ulcer with slough/eschar and large dimensions, again without physician notification. The DON acknowledged that weekly wound assessments with measurements and descriptions were not completed between 12/16/25 and 1/3/26 and that the wound did not change from a Stage 2 to a large unstageable ulcer overnight. Interviews with nursing staff indicated that the wound had gotten larger and worse, that the NP was told it looked worse, and that treatment orders were not changed from 12/16/25 until the resident was seen at a wound clinic on 1/2/26. Hospital records later documented a sacral decubitus ulcer with foul odor, significant necrotic tissue, and debridement down to ligamentous structures and exposed bone. The deficiency also includes failures in basic preventive care such as repositioning and incontinence management for Resident #29. The resident, who had multiple sclerosis and could not reposition herself, reported that staff were not turning her every 2 hours as ordered and that she had to set an alarm on her phone to prompt staff. She stated that some overnight shifts only repositioned her once late in the night and that she had reported these concerns multiple times. Staff interviews corroborated concerns that the resident was not being repositioned appropriately and that CNAs had reported the wound was not improving but were told to apply cream without the nurse assessing the area. There were also reports that a CNA refused to change the resident’s saturated brief, allegedly stating there were no briefs and reapplying the same brief, while another CNA described only “freshening up” the resident and not returning later in the shift. The DON and nursing staff acknowledged that CNAs may not recognize or report early pressure injuries, that CNA reports to nurses were sometimes undocumented, and that “a lot of balls were dropped” regarding wound care. For Resident #2, the deficiency includes incomplete and inaccurate wound assessment and documentation, and failure to align the care plan with identified skin risks and conditions. Resident #2 was admitted with a Braden score of 17 and a documented need for repositioning at least every 2 hours, and had incontinence-associated dermatitis (IAD) on the buttocks present on admission. Wound evaluations showed large fluctuations in the documented size of the IAD over time, including a significant increase in area on 12/5/25 and later a marked decrease by 12/30/25, followed by another large increase on 1/6/26. The 12/12/25 wound evaluation lacked any measurements, and a photo from 1/6/26 showed two areas consistent with Stage 2 pressure ulcers on the sacrum/coccyx that were not documented as such in the record. The MDS identified that the resident was at risk for pressure ulcers and had MASD, and that interventions such as pressure-reducing devices and nutrition/hydration interventions were in place, but the care plan only reflected a generic potential for pressure injury and did not include the specific skin issues or interventions identified on the MDS. Interviews and record reviews further demonstrated systemic issues contributing to the deficiencies. The NP reported that she was shown a picture of Resident #29’s wound on 12/16/25 and then only heard again around Christmas via a text that the wound looked worse and needed a wound care visit; she did not receive updates on the wound clinic’s findings and was not informed when the wound became unstageable or significantly deteriorated. She stated she would have expected notification with such changes and that the wound appeared preventable and should not have progressed to its current state. Nursing staff acknowledged expectations to notify physicians of wound changes, lack of improvement, or deterioration, but also acknowledged that this did not occur consistently for Resident #29. The DON confirmed that physician notifications and wound assessments were missing or incomplete, that CNA reports were sometimes not documented, and that there were multiple failures in wound care practices across the facility. Overall, the documented actions and inactions include failure to perform consistent, measurable weekly wound assessments; failure to document and communicate wound deterioration and infection to providers; failure to update care plans and interventions in response to new or worsening pressure ulcers; failure to ensure regular repositioning and timely incontinence care; and failure to accurately identify and document pressure ulcers versus dermatitis. These failures affected multiple residents, with detailed evidence for Residents #29 and #2, and were acknowledged by the DON and nursing staff as significant lapses in wound care and skin integrity management.
Failure to Involve Residents/Representatives and Update Interdisciplinary Care Plans for Changing Clinical Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop, review, and revise comprehensive care plans with an interdisciplinary team that included residents and/or their representatives, and to update care plans when residents’ conditions changed. Multiple residents and family members reported that care plan conferences had not occurred since a change in facility ownership, despite prior practice of quarterly meetings. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and diabetes, had a baseline care plan and a signed POA document, but there were no care conference attendance sheets, and the family stated they had not been included in care plan meetings since the new company took over. Another cognitively intact resident and that resident’s son both reported they had never been invited to care conferences since admission, and the social services director acknowledged that many care conferences were not completed and that residents and families had not been part of quarterly assessments. The facility also failed to revise care plans to reflect significant changes in residents’ clinical status and treatment orders. One resident with intact cognition and a right femur fracture was being transferred with a whole body mechanical lift per therapy evaluation and documentation, but the care plan still listed stand-pivot transfers with one staff and a gait belt; staff reported they had not received updated transfer information and expected therapy to update the care plan. Another resident with moderate cognitive impairment and multiple diagnoses had a care plan with 19 focus areas whose interventions had largely not been updated since the prior year, despite the facility no longer offering restorative nursing services; there was no EMR documentation of care conferences or timely updates, and late entries were added to progress notes only after surveyor inquiry. A resident who experienced a fall, hospitalization, and diagnosis of Influenza A had a marked decline in transfer ability and required a full-body mechanical lift and transmission-based precautions, but the care plan was not updated to reflect the new transfer status or the need for PPE until after surveyor review. Additional failures involved skin integrity and catheter-related care planning. One resident admitted with a Stage 2 pressure ulcer and later placed on and then removed from an indwelling urinary catheter had care plan interventions that continued to reference catheter care and Enhanced Barrier Precautions for the catheter after the catheter was discontinued by physician order; the MDS showed the resident as incontinent without a catheter, but the care plan was not revised. Another resident at risk for pressure injuries developed in-house acquired moisture-associated skin damage on the buttocks and a deep tissue injury on the right heel, with multiple wound treatment orders and documentation of a scoop mattress and lack of repositioning aids; however, the care plan did not include MASD, the DTI, or related interventions such as pressure-reducing devices or nutrition/hydration measures. A different resident admitted without pressure injuries developed in-house Stage 2 pressure ulcers on the buttocks and a DTI on the right heel; the care plan contained no prevention focus, goals, or interventions until after the wounds occurred. Further, residents with existing or worsening pressure injuries did not have their care plans revised to reflect new or escalated needs. One cognitively intact resident with an in-house Stage 2 sacral pressure ulcer later required surgical debridement of a Stage 4 sacral ulcer with exposed bone and a wound vacuum; the care plan showed a generic focus on potential for pressure injury and an in-house Stage 2 sacral ulcer but no new interventions after the ulcer progressed and the resident returned from the hospital with a wound vac and more advanced wound status. Another cognitively intact resident at risk for pressure ulcers developed unstageable skin on 12/23, but there was no care plan update or added interventions for this finding. Interviews with the MDS coordinator, DON, RN staff, and social services indicated that the MDS coordinator was primarily responsible for building and updating care plans, floor nurses generally did not update care plans, and care conferences were not consistently scheduled or documented with IDT participation, residents, or families, resulting in multiple care plans that were outdated, incomplete, or not reflective of current clinical orders and conditions.
Failure to Provide Ongoing, Understandable Education on Resident Rights
Penalty
Summary
The facility failed to provide ongoing education to residents and/or their representatives on Resident Rights in a format that was understandable to them. During a Resident Council meeting, residents present reported they were unaware that they had rights, did not know what their Resident Rights were, and did not know if these rights were posted within the facility. Review of Resident Council minutes for three consecutive months showed that various facility leaders attended the meetings but did not provide education on Resident Rights. During the same Resident Council meeting, the Life Enrichment Director stated she typically led the council and that an Activity Coordinator filled in when she was unavailable, and she acknowledged that staff had not been reviewing or educating residents on Resident Rights during these meetings. The DON stated that Resident Rights were provided only as part of admission packets and agreed they needed to be reviewed with residents on an ongoing basis, and neither the Life Enrichment Director nor the DON could confirm that Resident Rights were posted and readily available for residents, despite the facility’s Resident Rights policy stating that residents were to be informed of their rights and that these rights were to be posted throughout the facility. No specific resident medical histories or clinical conditions were described in relation to this deficiency, and the census at the time was 28 residents.
Failure to Provide and Document Oral Care, Toileting, and Repositioning for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required assistance with oral care, toileting, and repositioning for multiple dependent residents. For Resident #22, the Quarterly MDS dated 10/31/2025 showed a BIMS score of 4, indicating severe cognitive impairment, and documented a need for substantial/maximal assistance with oral hygiene. Her care plan, revised 11/18/2020, identified an ADL self-care performance deficit related to multiple sclerosis and required one staff to assist with daily grooming, including personal hygiene and oral care. A handwritten sign in her room requested that staff brush her teeth every day, and her emergency contact reported that her teeth were sometimes not brushed much when she visited, stating the resident would allow staff to complete oral care. On interview, the resident stated staff had not brushed her teeth that morning. The DON later stated she was unaware of the sign and that oral care should be completed at least twice a day, ideally by CNAs but also by nurses or other clinical staff, and possibly during OT. Resident #2’s MDS documented a BIMS of 15, indicating no cognitive impairment, and a need for supervision or touching assistance for oral hygiene. Her care plan, initiated 12/5/2025, documented that she required assistance of one staff for oral care. Review of her EHR showed no documentation of oral care provided. In interview, she stated she had a toothbrush in her bathroom and that whether oral care was provided depended on the staff. She reported that her husband helped her brush her teeth in the evenings, OT used to help her when she was going to therapy, and that occasionally a CNA would assist her with oral care. Resident #3’s MDS showed a BIMS of 11, indicating moderate cognitive impairment, and a need for partial/moderate assistance with oral hygiene. Her care plan, initiated 4/12/2025, documented that she required assistance of one staff for oral care, yet her EHR contained no documentation of oral care. Observation revealed no toothbrush in her room, and the ADON confirmed there was no equipment available to provide oral care. A CNA stated she had completed oral care that morning, claimed she obtained a new toothbrush for the resident every day, and said the resident only required set-up according to the care plan, which conflicted with the documented need for assistance. Resident #29’s MDS documented a BIMS of 15 and a need for supervision or touching assistance for oral hygiene, and her care plan dated 11/19/2025 indicated she required assistance of one for oral care. Her EHR contained no documentation of oral care. She reported that she had to set an alarm on her phone to ensure staff came to reposition her every two hours as ordered by her doctor, and that prior to a hospital stay staff were not repositioning her every two hours, with some overnight shifts only repositioning her at 3:00 or 4:00 AM. She stated she had multiple sclerosis, could not reposition herself in bed, and required staff assistance. She also reported that staff rarely provided oral care, that she could not sit up in bed on her own, and that she would appreciate staff assistance with oral care. She further stated that on one night a CNA refused to change her brief, that she was out of briefs and remained incontinent of urine without being changed all night, and that this CNA only repositioned her but did not change her. She reported prior concerns about this CNA’s care and described feeling treated without appropriate dignity or respect when requesting to be cleaned and changed. Resident #30’s MDS documented a BIMS of 13, indicating no cognitive impairment, and a need for substantial/maximal assistance with oral hygiene. Her care plan, initiated 12/3/2025, documented that she required assistance of one for oral care, yet her EHR contained no documentation of oral care. Her daughter reported that when she visited at random times, she frequently found food on the resident’s face and mouth and that it appeared her mother’s teeth had not been brushed. Staff interviews confirmed expectations and practices related to oral care: the ADON stated it was an expectation that all residents receive oral care even if they do not have teeth, and that dentures should be cleaned or soaked overnight. The DON stated oral care should be completed or offered and documented if refused, and that the required assistance should be reflected on the care plan. A CNA described asking cognitively intact residents when they wanted their teeth brushed and providing oral care before breakfast for residents who were not cognitively aware, and reported frequently finding residents with food on their faces and hands not cleaned from dinner, which she had brought to management’s attention. Review of the facility’s undated oral care policy showed that the purpose of the procedure was to keep lips and oral tissues moist, cleanse and freshen the mouth, and prevent oral infection. The policy required review of the care plan for special needs, assembly of needed equipment and supplies, and documentation in the medical record of the date and time mouth care was provided, the name and title of the person providing care, assessment data about the mouth, complaints of pain or discomfort, refusals with reasons and interventions, and the signature and title of the person recording the data. The policy also required CNAs to report to the licensed nurse for documentation. Despite these policy requirements and the care plan directives, surveyors found no documentation of oral care for multiple residents who required assistance, observed lack of oral care supplies in at least one resident’s room, and obtained resident and family reports that oral care, toileting, and repositioning were not consistently provided as needed.
Failure to Ensure Wheelchair, Mechanical Lift, and Hot Water Safety
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries related to wheelchair transport, mechanical lift use, and hot water temperature monitoring. For one resident with moderate cognitive deficit who used a manual wheelchair with staff assistance, a CNA pushed the resident approximately 240 feet through two hallways without wheelchair footrests in place. A nurse and another staff member observed and interacted with the CNA during this transport but did not stop the wheelchair movement despite facility expectations that residents must have footrests on before being pushed. Another resident with severe cognitive impairment, who was dependent on staff for manual wheelchair use, was observed being pushed by a CNA from the dining room to the living room with the resident’s feet dragging on the floor for about 75 feet, again without use of footrests. The facility also failed to ensure safe and consistent use of full body mechanical lifts for residents who required dependent transfers. One cognitively intact resident, fully dependent on staff for chair-to-bed transfers and care-planned for a full body mechanical lift with two staff, reported that some staff used only one person during lift transfers, while most used two. The resident, a nurse for 30 years, stated she knew two staff were required and that she had to ask staff to get a second person, expressing worry about ending up on the floor if the sling broke. Another resident with moderate cognitive impairment, also fully dependent for transfers, stated she did not like using the full body mechanical lift and instead grabbed staff around the neck while they placed her in the wheelchair, and that staff sometimes brought the lift into the room but then decided not to use it. Multiple staff interviews confirmed inconsistent and unsafe practices with mechanical lifts. One staff member stated he had been trained that lift use was based on manufacturer recommendations and that it could be used with only one person, and he reported concerns to an LPN without apparent follow-up. An RN reported seeing staff transfer residents requiring full body mechanical lifts with only one staff and stated that “all the staff do it all the time,” naming specific CNAs who frequently did so. Another RN acknowledged having to remind certain staff that two people were needed for full body lift transfers and that she had received reports of staff transferring residents alone. A CNA stated staff were not supposed to transfer residents alone with full body lifts but that when a nurse would not help, she transferred with only one staff. The facility further failed to protect residents from possible scalding injuries by not adequately monitoring and controlling hot water temperatures. Review of water temperature logs showed monthly readings in resident rooms and the laundry area, with some laundry temperatures documented above 140°F, and no temperatures recorded after mid-November. The Director of Plant Operations stated it was probably his job to review the temperatures monthly but admitted he did not do so and did not know what temperatures were too hot for resident rooms or showers, nor the appropriate high or low limits. The DON stated that 124°F for resident room water was “a little too hot” but was unsure of the correct temperature to prevent burns or the timeframe for burns to occur. The Administrator stated he was not a temperature expert, could not state the appropriate water temperature for showers or resident rooms, and was unsure whether the Director of Plant Operations had ever been trained on appropriate water temperatures. No policies were presented for appropriate water temperatures, full body mechanical lift use, or wheelchair transportation safety.
Failure to Assess and Treat Diabetic Ulcer and Head Injury for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assessment and treatment for a diabetic foot ulcer for one resident and failure to appropriately assess and monitor a head injury for another resident. For the first resident, the admission/readmission progress note dated 1/5/26 documented no impaired skin integrity, including no diabetic ulcer or open areas, despite the resident later being identified as having a diabetic ulcer on the second digit of the left foot. The resident, who had a BIMS score of 15 indicating no cognitive impairment, reported that she had informed the RN/ADON about the sore on her foot and that nothing was done until another RN intervened. The electronic health record showed that a wound evaluation entered on 1/15/26 documented a diabetic ulcer on the left second toe, present on admission, with specific measurements and description, and physician notification at that time. Further review of the records for this resident showed that the wound was again evaluated on 1/16/26 and 1/23/26 with documented measurements, but there was no documentation of any physician notification or treatment for the wound from the time of admission on 1/5/26 until 1/15/26, when the RN first addressed the area. A physician’s order to cleanse the second toe on the left foot and apply triple antibiotic ointment with a bandage daily had a start date of 1/15/26, indicating that treatment was not initiated until ten days after admission. The DON stated that the initial admission skin assessment was completed by one RN who left without documenting the assessment, and that the evening nurse then completed the assessment again. The DON also stated she did not think the initial nurse observed the resident’s foot or toe, acknowledged that the wound should have been noticed on admission, and confirmed that the resident was in the facility for a week without the wound being assessed or treated. For the second resident, who had a BIMS score of 13 indicating no cognitive impairment, the facility failed to appropriately assess and monitor a head injury and associated bruising. A skin check dated 12/22/25 documented no skin issues. On 1/4/26 in the morning, an LPN observed a scratch or red mark on the right side of the resident’s forehead and obtained an initial set of vital signs and an assessment as part of the daily assessment, but did not initiate neuro checks at that time and did not remove the resident’s clothing to assess hips or buttocks, only pulling pant legs up. The LPN reported conflicting accounts from the resident about how the injury occurred and stated she was not aware of any procedure for injury of unknown origin or for witnessed/unwitnessed head injury. Later that day, when the resident’s daughter arrived, the area on the forehead had progressed to a swollen “goose egg,” at which point neuro checks were started and the on-call provider was notified, with documentation showing neurological assessments beginning at 6:00 PM and a skilled note at 7:49 PM describing a hematoma to the right forehead and notifications made. The resident’s daughter reported finding her mother with a bruise on the knee and a wound on the right side of the head, and stated the resident told her she had fallen in the bathroom that morning. She also reported that additional large bruises on the right hip and right shoulder blade were only discovered and brought to attention when the resident was examined in the emergency department the following day. The DON acknowledged that there had been an injury of unknown origin and that staff had not notified the physician or family appropriately when the injury was first found in the morning, and that neuro assessments should have been initiated at that time but were not. The DON stated she would have expected staff to notify her, the physician, and the family when the head injury was first observed at approximately 7:30 AM, and confirmed that these actions were not completed as expected. The nurse practitioner stated she was notified of the forehead area and conflicting stories but was not made aware of the goose egg or any other bruising, and that she would have expected staff to call with any head injuries and start neuro assessments immediately.
Failure to Follow Physician Orders and Notify Providers Regarding Medication Administration
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not following physician orders for multiple residents. For one resident with severe cognitive impairment and multiple diagnoses, including atrial fibrillation, heart failure, and respiratory failure, the facility did not administer three prescribed medications, failed to obtain daily weights as ordered, and administered a medication despite the resident's pulse being below the prescribed parameter. Documentation was missing for several medication administrations and required monitoring. Another resident with severe cognitive impairment and multiple chronic conditions, including coronary artery disease, hypertension, and neurogenic bladder, experienced repeated refusals of several scheduled medications and supplements over multiple days. The facility did not notify the primary care provider of these refusals, both for single instances and for continuous refusals over three days, despite facility policy requiring such notification. The resident subsequently refused all medications, nutrition, and hydration for a period, and was later taken to the hospital by family with a diagnosis of complicated urinary tract infection and altered mental status. Staff interviews confirmed that the primary care provider was not notified as required. A third resident with normal cognition and diagnoses including anemia, atrial fibrillation, and renal insufficiency received medication outside of prescribed parameters, specifically antihypertensive medication when blood pressure or pulse was below the hold parameters. There was also a lack of documentation for vital signs required before administration of these medications, and medications were held without physician orders when no parameters were specified. Staff and administration interviews confirmed that documentation was lacking and that medications were administered or withheld outside of physician orders and facility policy.
Failure to Provide and Document Catheter Care and UTI Monitoring
Penalty
Summary
The facility failed to provide catheter care and monitoring in accordance with professional standards for three residents with indwelling catheters. For each resident, there were multiple instances where catheter output was not documented as required by physician orders and facility policy. In addition, the facility did not consistently monitor or report changes in eating patterns, which were identified in care plans as potential signs or symptoms of urinary tract infection (UTI). One resident with severe cognitive impairment and a history of atrial fibrillation, heart failure, and recent UTI had an indwelling catheter. The resident's treatment records showed missing documentation of catheter output on several shifts, and there was no evidence that changes in eating patterns were reported as required. The resident was hospitalized with severe sepsis due to UTI, with hospital records noting overt purulence in the catheter and abnormal urinalysis results. Another resident with neurogenic bladder and a suprapubic catheter also had multiple missed entries for catheter output and decreased nutritional and fluid intake that was not reported to the primary care physician. This resident was subsequently hospitalized for a complicated UTI, and the physician confirmed that notification should have occurred for decreased intake. A third resident with normal cognition and a history of anemia, renal insufficiency, and recent UTI also had an indwelling catheter. Documentation of catheter output was missing for several shifts across multiple months, and there was no supporting documentation in the medical record for these omissions. Interviews with nursing staff and facility leadership confirmed that lack of documentation indicated the task was not completed, and that the expectation was for catheter output to be recorded each shift as ordered. Facility policy required catheter bags to be emptied and output documented at least every eight hours, with unusual findings reported to the physician.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement appropriate infection prevention and control practices, specifically regarding hand hygiene and the use of Enhanced Barrier Precautions (EBP) during resident care for two out of three residents reviewed. Observations and record reviews revealed that staff did not consistently follow EBP protocols, such as wearing gowns and gloves during high-contact care activities, and did not always perform hand hygiene at required times, including between glove changes. The facility's own policies and posted signage required these precautions for residents with indwelling catheters, wounds, or pressure ulcers, but these were not always adhered to during care activities such as transferring, grooming, and catheter care. One resident with severe cognitive impairment, a suprapubic catheter, and a history of urinary tract infection was observed receiving care where staff initially followed infection control practices but failed to don gowns during subsequent high-contact activities like transferring and grooming. Another resident with an indwelling catheter, pressure ulcer, and multiple comorbidities was observed during care where staff changed gloves without performing hand hygiene, contrary to facility policy and CDC guidelines. Documentation also showed lapses in recording EBP implementation for this resident during certain shifts. Interviews with the Interim Director of Nursing and the Administrator confirmed that staff were expected to follow EBP protocols, including the use of gowns and gloves for high-contact care and hand hygiene between glove changes. However, direct observations and record reviews demonstrated that these expectations were not consistently met, resulting in a failure to fully implement the facility's infection prevention and control program as required.
Failure to Implement and Document Fall Prevention and Post-Fall Assessments
Penalty
Summary
The facility failed to provide appropriate interventions to prevent falls and did not complete required neurological assessments after unwitnessed falls for several residents. For one resident with severe cognitive impairment and a history of falls, the care plan was not updated with new interventions after multiple falls occurred on consecutive days. Progress notes documented repeated incidents of the resident being found on the floor, but no additional fall prevention strategies were added to the care plan following these events. Another resident experienced multiple unwitnessed falls, but the neurological assessment flow sheets showed that vital signs, level of consciousness, pupil response, motor functions, and pain response were not consistently documented as assessed after these incidents. This lack of documentation was also observed for another resident with severe cognitive impairment and a history of falls, where neurological checks were incomplete or missing after unwitnessed falls, despite facility policy requiring such assessments for a 72-hour period following an unwitnessed fall. Additionally, a resident with mild cognitive impairment and multiple medical diagnoses, including a history of falls, was observed with fall prevention equipment not consistently in use, such as a fall mat being folded and not placed by the bed. The care plan for this resident included general fall prevention measures, but after documented falls, there was no evidence of individualized interventions being added. Staff interviews revealed inconsistent knowledge and use of care plans and interventions, and the facility was unable to provide a current policy regarding fall interventions after a fall, relying instead on an outdated neurological assessment policy.
Failure to Update Facility Assessment Following Change in Ownership
Penalty
Summary
The facility failed to update its Facility Assessment to reflect current operations and resources necessary to care for its 26 residents. The most recent Facility Assessment provided was dated from July 2023 through June 2024 and still referenced the previous facility name, despite a change in ownership in February. The current CEO, acting as Administrator, confirmed that the assessment had not been updated since the new management took over. The Skilled Unit Manager/ADON reported being unable to access the previous owners' program to obtain policies and could not locate a relevant policy in the facility's binders. Additionally, corporate staff were asked to provide the policies they intended to implement, but as of several days after the request, no policies had been provided.
Failure to Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified individual to serve as the Infection Preventionist (IP) responsible for the infection prevention and control program. According to document reviews and staff interviews, the designated IP, who is also the MDS Coordinator, had not completed the required specialized training in infection prevention and control, having only started the modules in April. The Director of Nursing (DON) was also undergoing the same training, and both relied on a corporate nurse for assistance, who was not regularly present at the facility. The facility's policy required the IP to be adequately qualified and to have completed accredited continuing education, which had not occurred at the time of the survey. Further review revealed that the antibiotic stewardship program, which falls under the IP's responsibilities, was not up to date, as evidenced by an incomplete binder for the current year. Staff interviews confirmed uncertainty regarding the IP's prior training and the lack of completion of required documentation. Additionally, the facility was unable to provide updated policies from the new ownership when requested by surveyors, indicating a lack of clear guidance and oversight for the infection prevention and control program.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and homelike environment for its residents. Over several days, multiple dead June bugs were seen on the floor between exit doors near a resident room, and these were not removed despite repeated observations. Additionally, a family member reported that housekeeping had not cleaned her relative's room since admission, leading her to personally pick up debris from the floor and bathroom. Direct observations confirmed the presence of white debris by the resident's recliner, a white spot under chairs, and a brown stain running from the toilet bowl to its base in the bathroom. These conditions persisted over multiple days, even after the concerns were brought to the attention of facility leadership. Interviews with staff revealed that housekeeping is expected to clean resident rooms and bathrooms daily, typically with two housekeepers on duty, though sometimes only one is available. Despite these expectations, the staff member interviewed denied receiving any complaints from residents about cleanliness. The ongoing presence of debris and unsanitary conditions in the resident's room and bathroom, as well as the accumulation of dead insects in common areas, demonstrate a failure to provide a clean and safe environment as required.
Failure to Report Alleged Staff Misconduct to State Agency
Penalty
Summary
The facility failed to report an allegation of staff misconduct to the State Agency as required. A resident with a history of stroke, atrial fibrillation, coronary artery disease, heart failure, thyroid disorder, and sleep apnea, who required substantial assistance with activities of daily living and was cognitively intact, reported that a night shift CNA was rude, spilled a bedpan on her bed, denied the incident, and placed her call light out of reach. The resident also reported that the CNA told her she was using her call light too much and requested that this staff member not be allowed back in her room. The incident was witnessed by the resident's son, who corroborated the resident's account and added that the CNA called his mother 'crazy' and dismissed her concerns. The Director of Nursing (DON) conducted an internal investigation, which included speaking with the resident, her son, and the staff member involved. The DON provided education to the CNA regarding resident rights, infection control, and communication, and instructed her to stay out of the resident's room. However, the DON did not report the allegation to the State Agency, as required by regulation. The previous administrator, who was the Abuse Coordinator at the time, stated she was not fully informed of the incident and would have reported it had she known the full details. Other facility staff, including the Assistant Director of Nursing, were unaware that the incident had not been reported and assumed proper procedures had been followed. The facility was unable to provide a policy regarding the reporting of such incidents during the survey, and corporate staff did not supply the requested policies in a timely manner. The failure to report the allegation of staff misconduct to the State Agency constituted a deficiency in the facility's abuse reporting procedures.
Failure to Thoroughly Investigate Allegations of Staff Misconduct and Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of staff misconduct and abuse involving two residents. In the first case, a resident with a history of stroke, atrial fibrillation, coronary artery disease, heart failure, thyroid disorder, and sleep apnea, who required significant assistance with activities of daily living, reported that a CNA was rude, removed her call light out of reach, and spilled a bedpan on her bed. The resident's son and other staff corroborated aspects of her account, including the removal of the call light and the resident being upset. However, the facility's investigation did not include interviews with other staff who cared for the resident after the incident, nor did it include a comprehensive follow-up interview with the resident. Statements from involved staff were not formally documented, and other staff who were aware of the incident were not asked to provide statements. In the second case, another resident, recently admitted for rehabilitation after a fall and with a UTI, reported that staff were mean to her and described an incident involving a male staff member, which was not corroborated by staffing records. The resident exhibited confusion, paranoia, and combative behavior, as documented in progress notes and staff interviews. Despite these concerns, the facility's investigation was limited to a conversation with the resident's family and a single staff member. There was no evidence of interviews with other residents or staff who cared for the resident after the alleged incident, nor was there a thorough follow-up interview with the resident herself. Both cases demonstrated a lack of comprehensive investigation into allegations of staff misconduct and abuse. The facility did not follow a systematic process for interviewing all relevant parties, collecting written statements, or ensuring that all aspects of the allegations were explored. Additionally, the facility was unable to provide a policy regarding the investigation of abuse allegations, and there was no evidence that a thorough or standardized investigative process was followed.
Incomplete Comprehensive Care Plans for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to complete comprehensive care plans for two residents following their admission, as identified through observations, record reviews, and interviews. One resident was admitted with multiple stage 4 pressure ulcers and was at risk for developing additional pressure injuries. The care plan for this resident did not specify the type and location of the pressure ulcers, despite documentation in the Minimum Data Set (MDS) and the resident's own report of pressure ulcers on her right heel and bottom. Another resident, admitted with a stage 2 pressure ulcer and at risk for further skin breakdown, also had a care plan lacking details on the type and location of the pressure ulcer. Additionally, the care plan for this resident did not include interventions to prevent new pressure ulcers from developing. Staff interviews revealed that CNAs and LPNs relied on care plans for guidance on pressure ulcer care, including repositioning and maintaining skin integrity. However, the care plans reviewed did not provide individualized or comprehensive interventions, and staff reported not having access to care sheets. The MDS Coordinator and Assistant Director of Nursing confirmed that care plans should include specific information about the presence, monitoring, and treatment of pressure ulcers, as well as preventive measures, but these elements were missing or incomplete in the reviewed care plans. Further review indicated that the facility lacked a clear policy regarding the development and updating of comprehensive care plans, as the current management could not locate relevant policies from previous ownership or provide new ones. This lack of policy guidance contributed to the incomplete documentation and planning for residents with pressure ulcers, as evidenced by the care plans and staff statements.
Failure to Update Care Plans After Falls and Pressure Ulcer Development
Penalty
Summary
The facility failed to update and revise care plans for three residents after significant changes in their conditions, specifically following falls and the development of new pressure ulcers. For one resident with severe cognitive impairment and a history of falls, multiple falls were documented within a short period, but the care plan was not updated to reflect these incidents or to add new interventions. Another resident, who had mild cognitive impairment and was at risk for pressure ulcers, developed new stage 2 pressure ulcers in-house, yet the care plan lacked specific details such as the type and location of the ulcers and did not include interventions to prevent new pressure ulcers from developing. Additionally, this resident experienced multiple falls, but the care plan was not revised to address these events or to implement new fall prevention strategies. A third resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease and a history of falls, experienced several falls, one of which resulted in injury and hospitalization. Despite these incidents, the care plan was not promptly updated to reflect the new falls or to add or revise interventions. Staff interviews revealed that care plans were not consistently updated immediately after significant events, and there was confusion among staff regarding who was responsible for updating care plans and what information should be included. Some staff relied on the charting system to check for interventions, but care sheets were not available, and there was a lack of clear policy guidance on care plan revision. The facility was unable to provide a policy regarding care plan revision, and corporate staff did not supply requested policies in a timely manner. The lack of timely and comprehensive updates to care plans after significant changes in residents' conditions, such as falls and the development of pressure ulcers, was identified through observations, record reviews, and staff and resident interviews. This deficiency affected at least three residents in a facility with a census of 26 residents.
Failure to Document Completion of Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that treatment orders for pressure ulcer care were consistently signed out as completed for two residents. For one resident with a history of stroke, renal insufficiency, depression, and obesity, documentation showed that multiple treatment orders—including dressing changes, skin prep applications, ointment applications, and wound evaluations—were not signed out as completed on several dates across multiple months. The resident was identified as being at risk for pressure ulcers and had documented unhealed stage 1 pressure injuries. The care plan directed staff to administer medications and treatments as ordered, but the Treatment Administration Records (TARs) revealed repeated omissions in documentation of completed care. Another resident, who had no cognitive impairment and was at risk for pressure ulcers with three unhealed stage 4 pressure ulcers, also had multiple treatment orders not signed out as completed. These included wound evaluations, dressing changes, and specific wound care procedures for sacral and buttocks ulcers, as well as a puncture wound. The TARs for this resident showed numerous instances where required treatments and evaluations were not documented as completed over several months. Interviews with the resident indicated that dressings and treatments were performed daily, but staff interviews confirmed that if an order was not signed out on the TAR, it was considered not done. Further investigation revealed that the facility lacked a clear policy regarding the administration and documentation of treatment orders. The Assistant Director of Nursing (ADON) was unable to locate a relevant policy in the facility’s records or obtain one from the previous owners. Corporate staff were also unable to provide the requested policies by the time of the survey. This lack of policy guidance contributed to inconsistent documentation practices and the observed deficiencies in pressure ulcer care.
Insufficient Staffing Leading to Delayed Resident Assistance and Unsafe Transfers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by resident council notes, facility assessment, and interviews with residents and staff. The facility assessment documented staffing ratios of 1 LPN/RN to 15 residents on the day shift, 1 LPN to 30 residents on the overnight shift, 1 CNA to 10 residents on day and evening shifts, and 1 CNA to 15 residents on the overnight shift. Residents and staff reported that these staffing levels were inadequate, particularly on the overnight shift, resulting in delayed assistance for residents. One resident reported waiting up to 40 minutes for help, which led to incontinence episodes and feelings of humiliation, especially while managing a urinary tract infection. Staff interviews confirmed that there were often only two CNAs on the morning and evening shifts and only one CNA on the overnight shift. Staff acknowledged that due to insufficient staffing, mechanical lifts were sometimes operated by a single staff member, contrary to safe transfer practices, and that call lights were not answered promptly. The facility was unable to provide policies regarding call light response times and the use of mechanical lifts, and corporate staff did not provide requested policies after a change in facility ownership.
Incomplete Medical Record Documentation and Missing Incident Reports
Penalty
Summary
The facility failed to ensure that medical records for three residents were complete and accurate, as required by professional standards. For two residents, documentation of showers was incomplete, with records showing only two showers documented in the past 30 days, despite care plans indicating the need for showers twice a week. Both residents reported receiving showers as scheduled and had no complaints, but the records did not reflect this care. Additionally, for one resident with severe cognitive impairment and a history of falls, incident reports for two separate falls were missing from the records, even though progress notes described the incidents and subsequent actions taken. Interviews with staff revealed issues with access to the electronic charting system, leading to lapses in documentation of both baths and incident reports. The Assistant Director of Nursing acknowledged that some staff could not access the charting system, and that incident reports were sometimes completed by hand and not entered into the system. Furthermore, the facility was unable to provide policies regarding documentation practices, as the transition to new ownership had left staff without access to previous policies or clear guidance on documentation requirements.
Infection Control Breach During Food Preparation
Penalty
Summary
The facility failed to ensure proper infection control measures during food service, as observed with Staff F, the Culinary Supervisor. While preparing grilled cheese sandwiches, Staff F donned disposable gloves and then touched several non-food contact surfaces, including a bag of bread and the counter, before handling food. He used the same gloved hand to grab bread and cheese slices, butter the bread, and place it on the grill. This practice was contrary to the facility's policy, which required gloves to be changed whenever they became contaminated by touching non-food contact surfaces. The Dietary Manager acknowledged that staff were instructed to avoid using gloves unless necessary, as they tended to become complacent and touch surfaces before handling food.
Failure to Ensure Timely Completion of Mandatory Reporter Training
Penalty
Summary
The facility failed to ensure that all staff completed the required Dependent Adult Mandatory Reporter (DAMR) Training, as evidenced by the personnel file review of a Certified Nurse Aide (CNA), referred to as Staff E. The review revealed that Staff E's DAMR training certificate had expired, as it was last completed over three years ago. This deficiency was identified when the survey team requested the personnel file, and it was discovered that the training had not been renewed as required. The facility's policy mandates that associates receive training during orientation and through periodic educational sessions, which includes recognizing signs of burnout, frustration, and stress that may lead to abuse, as well as understanding what constitutes abuse, neglect, and misappropriation of resident property.
Infection Control Deficiencies in PPE Usage and Precaution Signage
Penalty
Summary
The facility failed to adhere to proper infection prevention practices for two residents under Enhanced Barrier Precautions (EBP). Resident #2, who had severe cognitive impairment and an indwelling catheter, was observed receiving catheter care from a CNA who did not properly wear the gown as required. The CNA rolled up the sleeves of the gown, contrary to the facility's policy and the CDC guidelines, which state that the gown should cover the arms to the end of the wrists. This improper use of personal protective equipment (PPE) was acknowledged by both the Director of Nursing and the Administrator, who confirmed that the facility's expectation was for the gown sleeves to be down over the wrist during catheter care. Resident #180, with moderate cognitive impairment and a lung infection, was supposed to be under droplet and contact precautions due to a recent influenza A infection. However, observations revealed that there was no eye protection available outside the resident's room, and no signage indicating the need for droplet precautions. Staff members, including an RN and a CMA, admitted to not wearing the required eye protection when caring for the resident, despite being aware of the droplet precautions. The lack of proper signage and PPE availability led to staff not fully adhering to the necessary precautions. The facility's failure to ensure proper infection control measures were in place and followed for residents on EBP and droplet precautions highlights a significant deficiency in their infection prevention and control program. The absence of appropriate PPE and signage, along with staff not following established protocols, contributed to the lapses in infection control for these residents.
Inaccurate MDS Assessment for Insulin Use
Penalty
Summary
The facility failed to accurately assess a resident's status during the observation period of the Minimum Data Set (MDS) by incorrectly documenting the use of insulin for one resident. The MDS for the resident indicated severe cognitive impairment and inaccurately recorded insulin injections and changes in insulin orders, despite the Medication Administration Record (MAR) showing no insulin orders. Instead, the resident was prescribed Trulicity, a glucagon-like peptide, administered subcutaneously every Monday. Staff interviews revealed a misunderstanding, with a Registered Nurse/MDS coordinator incorrectly identifying Trulicity as insulin. The Director of Nursing (DON) and the Administrator acknowledged the error, confirming the MDS was inaccurately coded and that the facility lacked a specific policy on MDS accuracy, relying instead on the Resident Assessment Instrument (RAI).
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents during personal care interactions. Resident #8, who has moderate cognitive impairment, reported feeling disrespected by Staff H, a CNA, who made dismissive comments when the resident struggled to stand up from the toilet. This incident was overheard by another resident, but despite being reported to Staff I, an LPN, it was not escalated to management. Resident #8 expressed that some staff were occasionally short with her, particularly when she required assistance after using the bathroom, although she did not feel abused. Resident #175, who has no cognitive impairment, also reported feeling disrespected by Staff H. The resident recounted being rushed and spoken to in a demeaning manner by Staff H during bathroom visits, which made her feel sad and hurt. Despite these feelings, Resident #175 did not report the incidents to other staff members. The facility's management, including the Administrator, Nurse Manager, and DON, were unaware of these incidents until the survey, indicating a breakdown in the reporting process. The facility's policy prohibits abuse, neglect, and exploitation, and mandates investigation of such allegations, but the incidents were not reported or investigated as required.
Deficiencies in Documentation and Medication Management
Penalty
Summary
The facility failed to adhere to professional standards of quality care for two residents, leading to deficiencies in documentation and medication management. Resident #172, who had a history of diabetes mellitus and was dependent on staff for various activities, experienced a low blood glucose reading. The staff did not document the specific glucose level, nor did they perform a follow-up check as required by the facility's hypoglycemia policy. The policy mandates prompt treatment with fast-acting carbohydrates and repeated glucose checks every 15 minutes, which were not conducted. The lack of documentation and follow-up was confirmed by staff interviews and a review of the resident's chart. Resident #9, who had diagnoses including heart failure and hypertension, experienced consistently low blood pressure readings. Despite these readings, the staff continued to administer hypertension medication without established parameters to determine when to hold the medication. The facility lacked a specific policy on blood pressure parameters, relying instead on nursing judgment. Interviews with staff revealed inconsistencies in how low blood pressure readings were handled, with some nurses holding the medication and others administering it without clear guidelines. The Medical Director mentioned standard parameters for holding medication, but these were not documented in the resident's care plan or MAR. The Director of Nursing acknowledged the absence of established parameters for Resident #9's hypertension medication, which led to inconsistent practices among the nursing staff. The Administrator confirmed that the facility did not have a policy on blood pressure parameters, which contributed to the deficiency. The lack of documentation and clear guidelines for managing low blood glucose and blood pressure readings resulted in a failure to meet professional standards of quality care for the residents involved.
Deficiency in Discharge Planning for Resident
Penalty
Summary
The facility failed to ensure that follow-up services and appointments were established before discharging a resident, leading to a deficiency in discharge planning. Resident #173, who had intact cognitive ability and required partial assistance with daily activities, was discharged to a hotel without securing home health services or follow-up appointments with a doctor. The resident had a history of orthostatic hypotension, type 2 diabetes mellitus, and chronic kidney disease, and was admitted for physical and occupational therapy. Despite the discharge plan indicating that the resident's needs could be met in a lower health setting, the resident expressed feeling scared and nervous about the discharge. The social worker attempted to arrange home health services and follow-up appointments but faced challenges with insurance acceptance and communication. The resident was locked out of his previous residence and had no family support, leading the social worker to arrange for a hotel stay. The social worker contacted three home health agencies, but only one accepted the resident's insurance, and there was a delay in paperwork processing. Additionally, the primary care physician's office had not received the necessary discharge paperwork from the facility, and the resident struggled to manage his diabetes and edema without the required medical supplies and support. The facility's discharge plan lacked documentation of arranged follow-up appointments, and there was a misunderstanding regarding the acceptance of the resident's insurance by the primary care physician's office. The Director of Nursing was only involved in the medication list transfer, while the social worker was responsible for follow-up appointments and services. The facility's policy required appropriate discharge planning and communication of necessary information to the continuing care provider, which was not adequately fulfilled in this case.
Failure to Assess and Manage Resident's Pain
Penalty
Summary
The facility failed to adequately assess and manage the pain of Resident #171, who was experiencing severe pain related to a fracture. Despite having a care plan that included administering pain medications as ordered, monitoring their effectiveness, and notifying the physician if pain management interventions were unsuccessful, the staff did not follow these directives. On 11/17/24, the resident did not receive any PRN pain medication, and there was a lack of pain assessments and vital signs documentation. The resident was noted to be screaming in pain throughout the day, yet the staff did not administer the prescribed Oxycodone or notify the physician as required. On 11/18/24, the resident continued to experience significant pain, which was not adequately assessed or managed by the staff. The resident received Tylenol and Cyclobenzaprine, but the documentation lacked a pain rating or comprehensive assessment. The resident's pain was later documented at a level of 9, and she was transferred to the emergency department at the request of her family and physician due to uncontrolled pain. Interviews with staff revealed inconsistencies in pain assessment and management, with some staff members acknowledging the resident's pain while others questioned whether it was genuine or behavioral. The facility's policy on pain management, revised in 2019, emphasizes the importance of effective pain assessment and management, including notifying the physician of new or worsening pain. However, the staff failed to adhere to this policy, as evidenced by the lack of pain assessments and failure to administer PRN medications or notify the physician. The Director of Nursing acknowledged the deficiencies in pain assessment and management, indicating that an assessment should have been completed and PRN medication administered when the resident's pain was reported.
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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