Country Lane Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Keosauqua, Iowa.
- Location
- 819 Country Lane Road, Keosauqua, Iowa 52565
- CMS Provider Number
- 165204
- Inspections on file
- 27
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 33
Citation history
Health deficiencies cited at Country Lane Manor during CMS and state inspections, most recent first.
A cognitively intact resident in COVID isolation gave a housekeeper cash on two occasions to purchase bottled water, chips, and a pencil sharpener. The resident reported that the staff member did not provide receipts, used part of the resident’s money to buy herself an energy drink, and failed to return the remaining change, resulting in an alleged loss of $17. The housekeeper acknowledged using $3 of the resident’s money for a personal drink and stated she intended to repay it later. Other staff reported that only designated personnel were supposed to handle resident shopping, and the facility’s abuse policy prohibited exploitation and misappropriation of resident property.
Surveyors identified multiple deficiencies in food storage, sanitation, and handling, including uncovered food in storage, expired milk and cheese in the refrigerator, and a microwave with dried residue. Staff were observed placing used spatulas directly on countertops during meal preparation, and interviews revealed inconsistent practices for checking expired food and cleaning kitchen equipment.
The facility experienced repeat deficiencies in bowel/bladder care, kitchen sanitation, and QAPI program implementation due to an ineffective QAPI process. Despite monthly Quality Assurance Committee meetings and a policy outlining data-driven improvement activities, the same issues were cited in consecutive recertification surveys.
A resident with moderate cognitive impairment and intellectual disability, who was frequently disoriented and unable to make complex decisions, did not have a designated representative for medical or financial decisions. Staff and administration confirmed that no attempts were made to identify or assign a POA, conservator, or guardian, despite facility policy and care plan directives requiring such action.
A resident with diabetes, paraplegia, and spina bifida was allowed to self-administer insulin without a documented assessment of safety or competency, as required by facility policy. The resident independently injected insulin under RN supervision, but the care plan and medical record lacked evidence of an interdisciplinary team assessment or documentation supporting the decision to permit self-administration.
The facility did not adequately promote or facilitate resident choice, resulting in a failure to support a resident's right to self-determination as required by regulation.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident with BPH, a recent UTI, and overflow incontinence was admitted with an indwelling urinary catheter, as documented in the MDS and physician orders. However, the care plan did not address the catheter or provide interventions for its care, despite facility policy requiring comprehensive care plans for all resident needs.
A resident with an indwelling urinary catheter and recent UTI did not have clear physician orders specifying catheter size, type, or change frequency, and the care plan lacked interventions for catheter care. Staff delayed obtaining a urinalysis due to miscommunication, and observations noted cloudy urine and resident discomfort. Interviews revealed confusion among staff about catheter care protocols and a lack of documentation consistent with facility policy.
The facility did not ensure that its QAPI group included all required members at quarterly meetings, as attendance records showed the Medical Director was present at only one meeting and the policy did not specify required attendees. The Administrator could not provide documentation to confirm additional attendance.
Staff failed to consistently follow infection prevention protocols for two residents with indwelling urinary devices. In one case, appropriate PPE was not used during urostomy care, and the care plan lacked direction for Enhanced Barrier Precautions. In another case, a nurse did not change gloves between cleansing a suprapubic catheter site and applying a new dressing. Facility policies did not adequately address these infection control procedures.
A resident with severe cognitive impairment and dementia experienced a delay in treatment for an eye infection when initial symptoms were reported to an LPN, but no timely provider response or intervention occurred. Only after a subsequent family complaint did an RN assess the resident and obtain an order for antibiotic eye drops, resulting in a delay in care.
The facility failed to serve food in an attractive and palatable manner during meal services. A resident reported that a chicken patty was hard and difficult to cut, while another resident found the mixed vegetables bland and the meal overly carbohydrate-heavy. Both residents had intact cognitive status and significant medical histories.
A resident with a history of necrotizing fasciitis and pressure ulcers did not receive the prescribed wound dressing changes due to a failure in implementing physician orders. Despite documented orders, staff were unaware or unclear about the new dressing orders, leading to a lack of action. The facility's process for handling treatment orders was not followed, resulting in the deficiency.
The facility failed to maintain consistent procedures for advance directives for six residents. Observations revealed incorrect or missing Full Code magnets on doors, and staff were often unaware of the correct code status. The administrator acknowledged the issues and considered removing the magnets due to their inaccuracy and potential for being moved by residents.
The facility did not perform Monthly Drug Regimen Reviews for July, affecting all 56 residents. The Administrator confirmed the absence of reviews and presented an email from a Consultant Pharmacist, who noted that recommendations from July were not completed and re-issued relevant ones. Facility policy requires monthly comprehensive medication regimen reviews, which were not conducted.
The facility failed to provide adequate nursing staff, impacting the admission process and resident care. Interviews revealed that only one nurse per shift often leads to incomplete admissions, with the absence of an ADON exacerbating the issue. The DON expressed concerns about minimal staffing levels, resulting in administrative staff covering nursing duties, leading to burnout and safety concerns. The CMS PBJ Staffing Data Report confirmed low staffing levels, particularly on weekends, affecting the facility's ability to meet resident needs.
The facility failed to maintain proper food safety and sanitation protocols. A cook did not change gloves appropriately during meal service, risking contamination. A resident food refrigerator lacked a thermometer and contained expired, undated food. The dishwasher log was incomplete, and cups appeared inadequately cleaned, indicating lapses in sanitation practices.
The facility's QAPI process failed to address previously identified deficiencies, resulting in repeated issues in areas such as resident rights, accommodation of needs, professional standards, and more. Despite monthly reviews by the Quality Assurance Committee, the same deficiencies were noted in consecutive surveys over six months.
A facility failed to implement a GDR for a resident's Duloxetine medication despite multiple recommendations from a consultant pharmacist and agreement from the primary provider. The resident continued to receive a 40 mg dose instead of the recommended 30 mg, with the MAR not updated to reflect the change. The resident's family disagreed with the reduction, but there was no prescriber documentation supporting this decision, and the resident had intact cognition.
A resident with intact cognition and a history of anxiety and depression expressed a preference not to be assisted by a specific CNA due to perceived rudeness. Despite assurances from the facility that the CNA would not return, the resident reported continued assistance from the CNA, violating the resident's rights to dignity and self-determination.
A resident with intact cognition but moderate hearing difficulty and limited vision reported being unable to access the bathroom sink with their wheelchair and experienced issues with a malfunctioning over-bed lamp. Despite voicing these concerns, no work orders were submitted, and the facility failed to address the resident's grievances, violating their policy on resident rights.
The facility failed to follow basic nursing principles for two residents, leading to significant deficiencies. A resident was readmitted without notifying the primary provider, resulting in missed medications. Another resident, under hospice care, was given morphine from another resident's bottle due to a lack of proper medication supply. Staff acknowledged these errors, highlighting issues in communication and medication management.
A facility failed to follow Provider's orders for a resident's indwelling catheter balloon size, leading to the use of an incorrect 30 mL balloon instead of the prescribed 10 mL. This error was discovered after the resident reported bladder pain and catheter malfunction. The facility's catheter care policy required staff to review care plans for special needs, which was not adhered to.
A facility failed to resubmit a PASRR level 2 approval within the appropriate time frame for a resident with Bipolar Disorder, Schizophrenia, and Dependent Personality Disorder. The resident required staff assistance and had a goal for community discharge. The care plan tasked the Director of Social Services with coordinating services before the PASRR expiration, but the approval expired without timely resubmission. The Facility Administrator acknowledged the lapse and planned an immediate new submission.
The facility failed to properly assess and intervene for two residents experiencing changes in condition. One resident with diabetes had hypoglycemia, but there was inadequate documentation and monitoring. Another resident experienced prolonged constipation, with the facility failing to follow its bowel management protocol. These deficiencies highlight lapses in documentation and adherence to care protocols.
The facility failed to provide adequate pressure ulcer care and monitoring for two residents, resulting in the development and worsening of wounds. Resident #20 developed a deep tissue injury and a stage two pressure ulcer, with inconsistent wound assessments and documentation. Resident #208 was admitted with multiple pressure ulcers that were not thoroughly assessed or consistently monitored. Staff interviews revealed confusion and miscommunication regarding wound care responsibilities, leading to inadequate treatment and documentation.
The facility failed to prevent falls and ensure safety for several residents, leading to multiple injuries. A resident with impaired cognition experienced several falls, including a hip fracture, due to inadequate supervision and lack of timely interventions. Another resident with moderately impaired cognition fell and fractured their hip while self-transferring, despite needing assistance. A resident with intact cognition was pushed in a wheelchair without proper foot pedal use, and another resident with communication difficulties experienced multiple falls due to inadequate preventive measures.
The facility failed to address the nutritional needs and weight loss of several residents, including those with dementia and impaired cognition. Residents experienced significant weight loss, and there was a lack of documentation and communication regarding their nutritional status. Additionally, ordered dietary supplements were often unavailable, contributing to the residents' nutritional deficiencies.
The facility did not ensure consistent access to resident funds outside business hours for five residents using the trust fund. The BOM stated funds were given if requested, but the Administrator admitted that 24-hour access was not consistently available. Facility policy required timely access to funds, which was not upheld.
Inadequate staffing at the facility resulted in several care deficiencies, including a fall with injury for a resident with impaired cognition, delayed toileting assistance leading to incontinence, and missed showers for another resident. Additionally, a resident with severely impaired cognition was observed struggling to eat without assistance. These incidents highlight the facility's failure to respond promptly to call lights and provide necessary care.
The facility failed to provide correct meal portions for residents on mechanical soft and pureed diets. The Dietary Manager did not follow the menu or facility policy, resulting in incorrect servings and missing pureed bread for some residents.
The facility failed to maintain kitchen sanitation and infection control during food service. The dishwashing machine operated below the required temperature, lacked testing strips, and had buildup. The handwashing sink was cold, and there was dust and food debris in the kitchen. The Dietary Manager improperly used gloves, touching various surfaces and serving food without changing them.
A resident with severely impaired cognition was left unassisted during meals, failing to receive timely encouragement or cues. Despite needing setup assistance, the resident struggled with eating, using utensils incorrectly, and was observed with spilled liquid on her lap without staff intervention.
A resident with an acquired absence of the left leg and other health issues was unable to access the sink in their bathroom due to its small size, impacting their independence and well-being. Despite the resident's intact cognition and ability to perform oral hygiene independently, the facility failed to address the issue after it was raised in a care conference. The ADON was unaware of the problem, and the facility's policy on accommodating needs was not followed.
A cognitively intact resident did not receive meal options or a menu, despite being on a regular diet, due to miscommunication and oversight by the facility staff. The resident expressed dissatisfaction, and staff interviews revealed that the Dietary Manager and ADON were unaware of the oversight, failing to uphold the resident's right to self-determination.
A facility failed to notify a resident of the termination of their Medicare Part A coverage. The issue was discovered through a review of clinical records, staff interviews, and policy reviews. The Assistant Director of Nursing acknowledged the absence of a discharge notice for the resident, who was discharged from Medicare Part A. The facility's policy requires notification of service termination and the right to appeal, but this was not adhered to.
The facility failed to complete a background check for an RN before her hire date and did not ensure a CNA had current mandatory reporter training. The Administrator acknowledged the expectations for these requirements, which are outlined in the facility's abuse policy.
The facility failed to ensure accurate MDS coding for several residents, leading to discrepancies in medication and treatment documentation. A resident's MDS indicated anticoagulant use without corresponding MAR documentation, while another resident's MDS failed to document a Foley catheter despite hospice records confirming its presence. Additionally, a resident's MDS did not reflect the administration of an antidepressant, despite daily administration documented in the MAR.
The facility failed to administer medications per physician orders for three residents. A resident with diabetes received insulin without clear parameters for holding doses, leading to inconsistent practices. Another resident missed doses of an anticonvulsant due to unavailability, and a third resident did not follow proper inhaler use instructions, with medication orders lacking dosages. Staff interviews revealed gaps in medication management and adherence to professional standards.
The facility failed to provide consistent assistance with ADLs for three residents, leading to deficiencies in care. A resident with quadriplegia was not properly groomed, another with impaired cognition did not receive necessary eating assistance, and a third resident missed scheduled showers. Staff confusion and inconsistent documentation contributed to these issues.
The facility failed to provide proper catheter care and documentation for two residents, leading to deficiencies. A resident with severely impaired cognition had a Foley catheter not documented in the facility's records, while another resident's catheter tubing was observed touching the ground, posing an infection control risk. Interviews confirmed that catheter tubing should not touch the floor, highlighting lapses in care and infection control practices.
A resident with multiple sclerosis and pressure ulcers had two active orders for hydrocodone/acetaminophen, leading to duplicate administration within the same 6-hour period. Staff interviews confirmed awareness of the duplicate orders, which violated the facility's medication administration policy.
The facility failed to implement gradual dose reductions (GDR) for two residents on psychotropic medications. One resident with intact cognition was prescribed Trazadone, and despite a pharmacist's recommendation for a GDR, no reduction was documented. Another resident with severely impaired cognition was prescribed Duloxetine, and although a GDR was agreed upon, it was delayed by two months. The facility's policy requires GDRs unless contraindicated.
Two residents did not receive bedtime snacks as desired, despite the facility's policy to offer them. Staff interviews revealed that snacks were not provided due to being busy and a lack of available snacks following a corporate change. The Dietary Manager noted budget-related issues with snack availability, although improvements were underway.
The facility failed to maintain an effective QAPI process, resulting in repeated deficiencies over 19 months. Citations included dignity, professional standards, and food procurement issues, with harm level citations for accident hazards/supervision. Despite a QAPI plan, the facility did not sustain improvements, leading to repeated citations.
The facility did not have a sufficient surety bond to cover the total amount of personal funds in the resident trust account for five residents. The surety bond amount was $40,000, but the total resident funds exceeded this amount. The facility's policy required a surety bond on the cumulative total of all resident trust fund balances, which was not adhered to.
Failure to Protect Resident From Financial Exploitation by Staff
Penalty
Summary
A resident with intact cognition, as evidenced by a BIMS score of 15 and the ability to clearly understand and make herself understood, reported giving a housekeeper money to make personal purchases on her behalf while she was in COVID isolation. The resident stated she had previously given this staff member money for shopping without problems and had always received receipts and correct change. On the date in question, she reported giving the housekeeper a $20 bill to purchase bottled water and chips; the staff member returned with three bottles of water and two bags of chips without a receipt, and the resident estimated the total should have been about $14. The resident further reported that she then gave the same staff member an additional $10 to purchase more bottled water and a hand-held pencil sharpener. According to the resident, the staff member returned with an electric pencil sharpener, stated it cost $7, did not provide a receipt, and told the resident she had used $3 of the resident’s money to buy herself an energy drink and would repay the money the next time she worked. The resident stated she did not see the staff member again and subsequently reported that the staff member owed her $17. A nurse interviewed described the resident as very alert and oriented, able to communicate her needs, and not known to exaggerate or make false statements. In interviews, the housekeeper acknowledged that the resident had asked her multiple times to purchase flavored bottled water and that she had shopped for the resident while cleaning her room. The housekeeper stated that on the most recent occasion she purchased water and chips with the $20, returned with the items, a receipt, and $6 in change, and then used $3 from a subsequent $10 given by the resident to buy herself an energy drink, intending to return the change later. Other staff interviews confirmed that there were designated staff responsible for resident shopping and that they were not aware the resident was asking non-designated staff to handle her money. The facility’s abuse policy defined exploitation as taking advantage of a resident for personal gain and prohibited misappropriation of resident property or exploitation by staff.
Deficient Food Storage, Sanitation, and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple failures in safe food storage, preparation, and sanitation practices within the facility's kitchen. During an initial tour, a partially uncovered leftover chocolate cake was found on a cookie tray in the dry goods storage area. In the walk-in refrigerator, a gallon of 2% milk was present with a date that had already passed, and the Dietary Manager initially believed milk was good for three days past the expiration date. An 18-quart container of shredded yellow cheese was also found with a date from nearly a month prior, and the Dietary Manager disposed of it upon discovery. Additionally, the inside of a microwave was noted to have dried tan residue, indicating it had not been properly cleaned. During a subsequent observation of the noon meal process, the microwave still contained dried residue. While preparing pureed and mechanical soft diets, a dietary staff member used different spatulas for each food item but placed them directly on the countertop without a barrier after checking food consistency. Interviews with dietary staff revealed inconsistent practices regarding checking for expired food and cleaning responsibilities. The Dietary Manager later confirmed that milk should be discarded by the expiration date and noted that a significant quantity of milk had to be thrown away due to improper rotation. The night staff was identified as responsible for nightly checks of refrigerated items for outdated food.
Repeat Deficiencies Due to Ineffective QAPI Process
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process, resulting in the recurrence of three specific deficiencies—F690 (Bowel/Bladder, Incontinence, Catheter, UTI), F812 (Food Procurement, Store/Prepare/Serve-Sanitary), and F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt)—that were previously cited during the 2024 recertification survey and cited again in the most recent recertification survey. The facility had a census of 51 residents at the time of the survey. Staff interviews revealed that the Quality Assurance Committee met monthly and selected focus areas based on grievances, resident council feedback, and 5-star report data, but did not prevent the recurrence of these deficiencies. Review of the facility's QAPI policy indicated a commitment to a comprehensive, data-driven program with specific processes for developing performance indicators, data collection, goal setting, and communication of findings. However, despite these outlined procedures, the facility continued to experience repeat deficiencies in the same areas, indicating that the QAPI process as implemented was not effective in preventing the reoccurrence of issues related to bowel/bladder care, kitchen sanitation, and the QAPI program itself.
Failure to Designate Resident Representation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to attempt to designate a representative for a resident with moderate cognitive impairment and intellectual disability, resulting in the absence of a surrogate to make informed medical and financial decisions on the resident's behalf. The resident, who had a BIMS score of 9 indicating moderate cognitive impairment, was diagnosed with mild intellectual disabilities, mood disorder, psychotic disorder, anxiety disorder, and depression. The resident's care plan identified the need to determine if an appropriate family member, friend, or support person could serve as Power of Attorney (POA), conservator, or guardian, and if not, to refer to the Office of Substitute Decision Maker. However, the admission record listed only the resident as a contact, and there was no documentation of attempts to identify or designate a representative. Staff interviews confirmed that the resident was often disoriented, unable to make complex decisions, and required assistance with medical and financial matters. Despite this, the Director of Social Services denied making any attempts to designate a conservator, guardian, or POA, and the facility administrator confirmed there was no record of such efforts. The facility's policy required assessment of decision-making capacity and identification of a primary decision-maker if the resident lacked capacity, but this process was not followed for the resident in question.
Failure to Complete Self-Medication Assessment Prior to Resident Self-Administering Insulin
Penalty
Summary
A deficiency occurred when the facility failed to complete a self-medication assessment for a resident with type 2 diabetes mellitus, paraplegia, and spina bifida, who was observed self-administering insulin. The resident had an intact mental status, as indicated by a BIMS score of 15 out of 15, and was receiving insulin injections daily. During an observation, a registered nurse prepared the resident's insulin pen, and the resident independently cleaned the injection site and administered the insulin, while the nurse supervised and disposed of the needle. Review of the resident's care plan and electronic health records revealed no documentation of a self-medication assessment or identification of the resident's request to self-administer insulin. Staff interviews confirmed that no assessment had been completed prior to the resident self-administering medication, despite facility policy requiring an interdisciplinary team determination and documentation of safety and appropriateness before allowing self-administration. The care plan also lacked interventions addressing the resident's self-administration of insulin.
Failure to Support Resident Self-Determination
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Include Indwelling Catheter in Care Plan
Penalty
Summary
The facility failed to include the use of an indwelling urinary catheter on the care plan for a resident who had a history of benign prostatic hyperplasia (BPH), a recent urinary tract infection (UTI), and overflow incontinence. The resident was admitted with an indwelling catheter, as documented in the admission Minimum Data Set (MDS) and physician orders, which specified the catheter was to be changed every 30 days for BPH and overflow incontinence. Despite these documented needs, the care plan initiated and later revised for the resident did not address the presence of the indwelling catheter or provide any interventions or directions for its care. Observation confirmed the resident had an indwelling catheter in use, with the tubing and drainage bag stored under the wheelchair and urine visible in the tubing. Staff interviews further verified that the resident had the catheter since admission for the stated medical reasons. The facility's own policy requires comprehensive, person-centered care plans that include measurable objectives and services to meet residents' needs, but this was not followed in the case of the resident with the indwelling catheter.
Failure to Clarify Catheter Orders and Timely Follow-Up on Urinalysis
Penalty
Summary
The facility failed to clarify and document appropriate orders for indwelling urinary catheter care and did not follow up on a urinalysis order in a timely manner for a resident with a history of benign prostatic hyperplasia, recent urinary tract infection, and overflow incontinence. The resident required an indwelling urinary catheter and was always incontinent of bowel. Upon review, the care plan did not identify the need for an indwelling catheter or provide interventions for catheter care, and the physician's order lacked details such as catheter size, type, and frequency of change. The treatment administration records for two months also did not specify these details, and the facility's policy on catheter care was not consistently followed. Observations revealed the resident's catheter tubing and drainage bag were stored under the wheelchair, with urine appearing cloudy. Nursing notes documented cloudy and foul-smelling urine, resident complaints of discomfort, and delays in obtaining a urinalysis due to a fax being sent to the wrong provider. The last documented catheter change was prior to admission, and there was confusion among staff regarding the frequency of catheter changes and the need for specific physician orders. The resident experienced discomfort and mucousy discharge upon catheter change, and a urinalysis was eventually collected after the new catheter was inserted. Interviews with nursing staff and the DON confirmed a lack of clear orders for catheter size and change frequency, as well as uncertainty about follow-up with urology. The facility's policy required observation and reporting of complications associated with urinary catheters, but this was not consistently implemented. The administrator acknowledged that orders for catheter care and documentation should have been in place, and the care plan should have reflected the use and management of the urinary catheter.
QAPI Meetings Lacked Required Members
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) group included the minimum required members at its quarterly meetings. Review of QAPI attendance records since the last recertification survey showed that the Medical Director was present at only one meeting, despite multiple meetings being held during the review period. During an interview, the Administrator acknowledged that the facility's QAPI policy does not specify which members must be present at the quarterly meetings and was unable to provide documentation to confirm the Medical Director's attendance at more than one meeting. The facility reported a census of 51 residents at the time of the review.
Failure to Follow Infection Prevention Protocols for Residents with Indwelling Urinary Devices
Penalty
Summary
The facility failed to follow infection prevention protocols for two residents with indwelling urinary devices. For one resident with a urostomy and colostomy, staff did not consistently use Enhanced Barrier Precautions as required. During care, a CNA donned appropriate personal protective equipment (PPE) when emptying the colostomy bag but failed to wear an isolation gown when emptying the urostomy bag, despite facility expectations and staff interviews confirming that a gown, gloves, and face shield should be used. Additionally, the resident's care plan lacked specific direction regarding Enhanced Barrier Precautions during device care, and the facility's catheter care policy did not address the need for such precautions for residents with indwelling urinary devices. For another resident with a suprapubic catheter, a nurse cleansed the catheter insertion site while wearing gloves but did not change gloves before applying a new dry dressing, contrary to facility expectations and staff interviews. The nurse acknowledged forgetting to change gloves during the observed care. The facility's policy on suprapubic catheter care did not include steps for applying a clean dry dressing, contributing to the lack of adherence to infection control protocols.
Delayed Treatment for Eye Infection
Penalty
Summary
A deficiency occurred when the facility failed to initiate timely treatment for an eye infection in a resident with severe cognitive impairment and a diagnosis of non-Alzheimer's dementia. On one occasion, the resident's family alerted a nurse to symptoms including a swollen, reddened, and draining right eye, with the resident also reporting itchiness and pain. The nurse documented the symptoms and completed a communication form for the provider, but there was no documented response from the nurse practitioner or physician at that time. It was not until several days later, after another family member again raised concerns about the resident's eye, that a registered nurse assessed the resident and contacted the physician, resulting in an order for antibiotic eye drops. The delay in provider notification and initiation of treatment did not align with professional standards of practice, as the resident's symptoms persisted for several days before appropriate medical intervention was started.
Deficiency in Food Palatability and Presentation
Penalty
Summary
The facility failed to serve food in an attractive and palatable manner during meal services, as observed during a survey. On one occasion, a sample lunch tray provided to the State Agency included a chicken patty and green beans. The chicken patty was noted to have hard, tough, and chewy edges, while the green beans were acceptable. Additionally, a puree version of the green beans served to a resident appeared to be of a soup consistency. Resident #7, who had an intact cognitive status and was independent in most activities, reported that the chicken patty was hard and difficult to cut, and mentioned that meats served are often hard. On another occasion, a sample lunch tray included spaghetti, mixed vegetables, and a seasoned breadstick. While the food was served at a palatable temperature, the mixed vegetables were described as bland. Resident #1, who also had an intact cognitive status but required moderate assistance with daily activities, complained about the meal, noting that the mixed vegetables were bland and the meal consisted mainly of carbohydrates. Both residents had significant medical histories, including conditions such as congestive heart failure and diabetes mellitus.
Failure to Implement Physician's Wound Dressing Orders
Penalty
Summary
The facility failed to implement a physician's order to change the type of wound dressing for a resident with wounds. The resident, who has a history of necrotizing fasciitis, diabetes mellitus, and wound infection, was admitted with two Stage III pressure ulcers and surgical wounds. The resident required assistance with certain activities of daily living and had specific physician orders for wound care, including the use of Vashe wound sol therapy and specific dressings for the left heel and buttock wounds. Despite the physician's orders being documented on 11/1/24, the clinical record did not show evidence of these orders being implemented. Interviews with staff revealed a lack of awareness and communication regarding the new dressing orders. Staff B, a registered nurse, did not see the new dressing orders in the electronic medical record and was unsure why they were not processed. Staff A, an advanced registered nurse practitioner, was not informed about the unavailability of supplies or the failure to implement the new dressing orders. Staff C, another registered nurse, was unclear about the wound dressing orders and assumed the night or weekend nurse would handle them. The facility's administrator and director of nursing expected the orders to be entered into the computer and implemented promptly. However, the process for handling and recording treatment orders was not followed, leading to the deficiency. The facility's policy on medication orders outlined the need for specifying treatment, frequency, and duration, but this was not adhered to in this case.
Inconsistent Advance Directive Procedures
Penalty
Summary
The facility failed to maintain a consistent plan and procedure for advance directives for six residents. The deficiencies were identified through observations, clinical record reviews, and staff interviews. For Resident #9, the electronic health record (EHR) did not indicate a code status, and a Full Code magnet was incorrectly placed on the door, indicating the wrong bed. Similarly, Resident #17's Full Code magnet was placed on the wrong side of the door, indicating the incorrect bed. Resident #19's EHR indicated a Do Not Resuscitate (DNR) status, but a Full Code magnet was incorrectly placed on the door, and staff were unaware of the magnet's significance. Resident #34's EHR indicated a Full Code status, but there was no magnet on the door, and staff were initially unaware of the resident's code status. Resident #42 also lacked a magnet on the door despite being a Full Code, as verified by staff. Resident #60's EHR failed to indicate a code status, and there was no signed Policy for Resuscitative Services document. Additionally, there was no Full Code indicator magnet outside the resident's room. The facility's administrator acknowledged the issues with the advance directives and expressed concerns about the accuracy and reliability of using magnets to indicate code status. The administrator mentioned plans to discuss the potential removal of magnets with the Director of Nursing (DON) due to the difficulty in maintaining their accuracy and the possibility of residents moving them.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to conduct Monthly Drug Regimen Reviews for the month of July, affecting all 56 residents. During a review of the monthly pharmacy reviews, it was discovered that no reviews were performed for any residents in July. On September 10, the Administrator confirmed that no pharmacy review was conducted in July and presented an email from a Consultant Pharmacist. This email, dated August 8, indicated that the Consultant Pharmacist noted the absence of completed recommendations from July and re-issued any relevant recommendations. The facility's policy, dated 2006, mandates that a consultant pharmacist perform a comprehensive medication regimen review at least monthly, which includes evaluating the resident's response to medication therapy and reporting findings to the director of nursing, attending physician, medical director, and, if appropriate, the administrator.
Insufficient Nursing Staff Leads to Admission Process Issues
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of its residents, as evidenced by interviews and document reviews. Staff C, an RN, highlighted issues with the admission process, noting that there is often only one nurse on the floor per shift, which hampers the ability to complete admissions properly. The absence of an Assistant Director of Nursing (ADON) has further complicated the process, leading to delays in reviewing and confirming admission orders. The Director of Nursing (DON) expressed concerns about staffing levels, indicating that the facility operates with minimal staff, which has resulted in administrative staff, including the Administrator, having to fill in for nursing duties. This situation has led to staff burnout and raised concerns about the safety of both residents and staff. The facility's staffing issues are further corroborated by the Center for Medicare and Medicaid Services PBJ Staffing Data Report, which triggered a One Star Staffing Rating and noted excessively low weekend staffing. The facility's policy, revised in October 2017, states that sufficient numbers of staff with the necessary skills and competencies should be available to meet resident needs. However, the review of daily nursing schedules from August to September 2024 revealed that staffing levels were inadequate, particularly during night shifts and weekends, when the facility had a census of 56 residents. This deficiency in staffing has impacted the facility's ability to provide timely and safe care, as well as to promote the residents' rights and well-being.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation protocols during meal service and food storage. During an observation, it was noted that a cook did not change gloves at appropriate times, handling various surfaces and food items without changing gloves, which could lead to contamination. Additionally, a refrigerator used for resident food storage lacked a thermometer and temperature log, and contained expired and undated food items such as shredded lettuce, whipped cream, mozzarella cheese, eggs, and yogurt. This indicates a failure to ensure that resident food was stored at appropriate temperatures and that expired food was removed. Furthermore, the facility did not maintain proper dish sanitation practices. The dishwasher log, which was supposed to record safe wash and rinse temperatures three times a day, lacked many entries, particularly in the evenings. The dishwasher was required to operate at specific temperatures for effective sanitation, but the log did not consistently reflect this. Additionally, cups used for service appeared to have a white film, suggesting inadequate cleaning. These deficiencies highlight lapses in the facility's adherence to its own policies regarding food storage and dish machine use, which require regular temperature checks and proper labeling and dating of food items.
Repeat Deficiencies in QAPI Process
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies. This resulted in multiple repeat deficiencies identified during the current recertification and complaint survey, which were also noted in surveys conducted over the past six months. The deficiencies were related to resident rights and dignity, reasonable accommodation of needs, services meeting professional standards, bowel and bladder incontinence or catheter use, sufficient nursing staff, psychotropic drug use, food procurement, storage, service, and sanitation, and the QAPI program itself. The facility's QAPI program, as outlined in their policy revised in February 2020, was intended to measure and improve outcomes of care and quality of life, establish performance improvement projects, and monitor corrective actions. However, despite these objectives, the facility continued to have repeat deficiencies in the same areas. The Administrator acknowledged these ongoing issues and indicated that the facility's Quality Assurance Committee meets monthly to review concerns, but the repeat deficiencies suggest that the QAPI process was not effectively addressing the identified problems.
Failure to Implement Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to implement a Gradual Dose Reduction (GDR) for a resident taking Duloxetine, an antidepressant medication, despite multiple recommendations from a consultant pharmacist and agreement from the resident's primary provider. The pharmacist initially recommended reducing the dose from 40 mg to 30 mg in November 2023, and the provider agreed to this recommendation. However, the facility did not update the Medication Administration Record (MAR) to reflect this change, and the resident continued to receive the higher dose. Throughout several months, the consultant pharmacist repeatedly noted that the dose reduction had not been implemented, despite the provider's agreement. The pharmacist's reports from January, March, April, and May 2024 all documented that the MAR still listed the 40 mg dose, and the pharmacist continued to recommend updating the MAR to the correct dosage. A handwritten note by an LPN indicated that the resident's family disagreed with the dose reduction, but there was no documentation from the prescriber supporting the family's wishes over the agreed-upon GDR. The resident's care plan noted the family's disagreement with the GDR, but the facility was unable to provide documentation from the prescriber to justify not following through with the dose reduction. The administrator acknowledged the oversight and confirmed that the provider had agreed to the GDR, but the order was never implemented. The resident had a documented Brief Interview for Mental Status (BIMS) score indicating intact cognition, raising questions about the decision-making process and the lack of documentation supporting the family's influence over the medication regimen.
Failure to Respect Resident's Choice of Caregiver
Penalty
Summary
The facility failed to respect a resident's choice of caregivers, leading to a deficiency in honoring the resident's rights to dignity and self-determination. Resident #18, who had intact cognition and a history of anxiety disorder, depression, and neuropathy, expressed a preference not to be assisted by a specific CNA, Staff F, due to perceived rudeness and meanness. Despite this, the resident reported that Staff F continued to assist with care, contrary to the resident's wishes and assurances given by the facility that the CNA would not return to the resident's room. The facility's failure to adhere to the resident's preferences was documented through multiple entries in nursing progress notes and behavior logs, which indicated repeated refusals of care by the resident and complaints about the CNA's behavior. The facility's policy on resident rights, which includes the right to choose providers and voice grievances, was not upheld in this instance, as evidenced by the continued involvement of Staff F in the resident's care despite the resident's explicit objections.
Failure to Ensure Accessibility and Functionality in Resident's Room
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not ensuring accessibility to a hand washing sink and a functioning overhead lamp in the resident's room. The resident, who had intact cognition but moderate hearing difficulty and limited vision, reported being unable to maneuver their wheelchair into the bathroom to access the sink. Additionally, the resident experienced issues with the over-bed lamp, which required excessive force to operate and often did not work. These issues were observed during a survey, and the resident expressed their concerns to staff members. Despite the resident's grievances, the facility's maintenance staff reported that no work orders had been submitted regarding the sink accessibility or the malfunctioning lamp. The facility's policy on resident rights, which includes the right to voice grievances and have them addressed, was not adhered to in this case. Staff members were aware of the resident's difficulties but did not take appropriate action to resolve the issues, leading to the deficiency noted in the report.
Medication Management Failures for Two Residents
Penalty
Summary
The facility failed to ensure that basic nursing principles were followed for two residents, leading to significant deficiencies in care. Resident #9 was readmitted to the facility from a hospital stay, but the primary provider was not informed of the readmission. As a result, Resident #9 did not receive several critical medications, including those for stroke prevention, diabetes management, and depression, among others. Interviews with staff revealed that the medication orders from the hospital discharge were not properly reviewed or transcribed, leading to a lapse in medication administration. Resident #20, who was under hospice care and actively dying, was prescribed liquid morphine for pain management. However, the facility did not obtain a bottle of liquid morphine for this resident. Instead, Staff C administered morphine from another resident's bottle, which was against facility policy. The DON later confirmed that liquid morphine was available in the facility's emergency kit, but Staff C was unaware of this resource. This oversight resulted in the improper administration of medication to Resident #20. The report highlights the facility's failure to maintain proper communication and medication management protocols, as evidenced by the lack of notification to the primary provider and the inappropriate use of another resident's medication. These deficiencies were acknowledged by the facility's staff, including the Facility Administrator, Nurse Practitioner, and DON, who recognized the errors in medication administration and the need for adherence to established policies.
Failure to Follow Catheter Balloon Size Orders
Penalty
Summary
The facility failed to adhere to the Provider's orders regarding the indwelling catheter balloon size for a resident with a neurogenic bladder and urinary retention. The resident's care plan specified the use of a 16 French catheter with a 10 mL balloon, which was confirmed by a telephone order. However, the Medication/Treatment Administration Record indicated the use of a 15 mL balloon, and a subsequent urology appointment revealed that a 30 mL balloon was in place, which was incorrect and could cause complications. The resident experienced bladder pain and reported that the catheter was not functioning properly. The urology provider noted that the incorrect balloon size could lead to the catheter sitting too high in the bladder, preventing proper drainage. Despite the resident's complaints of abdominal pressure, the facility staff did not follow the specified orders, as confirmed by the Director of Nursing, who expected adherence to the Provider's instructions. The facility's catheter care policy required staff to review the care plan for any special needs, which was not followed in this case.
Failure to Resubmit PASRR Level 2 Approval Timely
Penalty
Summary
The facility failed to resubmit a short stay approval for a Pre-Admission Screening Resident Review (PASRR) level 2 within the appropriate time frame for one resident. The resident, who had a Minimum Data Set (MDS) indicating intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was diagnosed with Bipolar Disorder, Schizophrenia, and Dependent Personality Disorder. The resident required partial to moderate staff assistance and had a goal for discharge to return to the community. The care plan assigned the Director of Social Services the responsibility to contact local providers before the expiration of the time-limited PASRR determination, which was set to end on a specific date. However, the PASRR level 2, which initially approved a 180-day short stay due to the resident's health status and anticipated support needs, expired without a timely resubmission. The Facility Administrator acknowledged the expiration and indicated that a new submission would be sent immediately.
Deficiencies in Resident Assessment and Intervention
Penalty
Summary
The facility failed to conduct proper assessments and interventions for two residents experiencing changes in their conditions. Resident #10, who had a history of diabetes mellitus, experienced hypoglycemia with a blood glucose level of 60 mg/dL. Despite initial interventions with glucagon packets and orange juice, the resident's blood glucose level only rose to 75 mg/dL, prompting further intervention with an intramuscular glucagon injection. However, there was a lack of documented assessments between the initial incident and the subsequent transfer to the hospital, indicating a deficiency in monitoring and documentation. Resident #209, who was recently admitted and had not yet completed an MDS assessment, experienced constipation for several days. Despite the resident's report of not having a bowel movement for five days, the facility's bowel protocol was not effectively implemented. The resident received Milk of Magnesia and an enema, but there was no record of receiving Senna-time tablets as ordered. The facility's staff failed to notice the issue on the third day, and the resident did not have a bowel movement from April 25 to May 2, highlighting a deficiency in following the bowel management protocol. The facility's policy on conducting accurate resident assessments was not adhered to, as evidenced by the lack of documentation and timely interventions for both residents. The Assistant Director of Nursing acknowledged the need for more thorough documentation and adherence to protocols, particularly in monitoring residents' conditions and ensuring that all necessary interventions are carried out as per the care plans and physician orders.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to implement timely interventions for residents identified at high risk for pressure ulcer development and to prevent worsening of wounds. For Resident #20, the facility did not consistently monitor, stage, or measure wounds. The resident developed a deep tissue injury to the right heel and a stage two pressure ulcer to the coccyx. The care plan for Resident #20 was not adequately followed, as evidenced by the lack of documentation for treatment to the coccyx and inconsistent wound measurements. Observations revealed that the resident's wounds were not properly assessed or documented, and there was confusion among staff regarding who was responsible for measuring and staging the wounds. Resident #208 was admitted with multiple pressure ulcers, including a stage four pressure ulcer on the right hip, a stage three pressure ulcer on the left heel, and a stage two pressure ulcer on the right ankle. The facility failed to thoroughly assess these wounds upon admission and did not consistently monitor, stage, or measure them. The resident reported that the facility only measured his wounds twice, despite his understanding that his insurance required weekly measurements. Interviews with staff revealed a lack of clarity and consistency in the documentation and assessment of the resident's wounds. The facility's policy on skin and wound management was not effectively implemented, as evidenced by the lack of consistent wound assessments and documentation. Staff interviews indicated confusion and miscommunication regarding the responsibilities for wound care and documentation. The facility did not have a dedicated wound care nurse, and the responsibility for wound assessments was not clearly assigned, leading to inadequate monitoring and treatment of pressure ulcers for the residents involved.
Failure to Prevent Falls and Ensure Safety
Penalty
Summary
The facility failed to ensure an environment free of accidents and hazards for several residents, leading to multiple falls and injuries. Resident #42, who had impaired cognition and was at risk for falls, experienced several falls resulting in injuries, including a fracture of the right hip. Despite being identified as at risk for falls, the care plan for this resident lacked timely interventions, and the facility did not implement adequate supervision or preventive measures. The resident continued to fall even after returning from the hospital, indicating a lack of effective fall prevention strategies. Resident #19, with moderately impaired cognition and a history of falls, also experienced a fall resulting in a right hip fracture. The resident self-transferred despite needing assistance, and the facility's interventions, such as the use of alarms, were not effective in preventing the fall. Staff interviews revealed that the resident was non-compliant with using the call light and often attempted to self-transfer, which contributed to the fall. Resident #211, who had intact cognition but required assistance with wheelchair locomotion, was observed being pushed in a wheelchair without both foot pedals in use. This practice was against the facility's policy of ensuring foot pedals are used when pushing residents in wheelchairs. Additionally, Resident #18, who was rarely understood and had a history of falls, experienced multiple falls due to attempting to sit in chairs and missing them. The facility's interventions, such as ensuring proper footwear and using a Broda chair, were not sufficient to prevent these falls.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to develop and implement interventions to prevent or treat weight loss for several residents. Resident #52, who had diagnoses including dementia and adult failure to thrive, experienced a significant weight loss of 6.81% over a short period. Despite this, the care plan did not address the weight loss, and there was no documentation of provider notification or further interventions from mid-April until the survey. Observations showed the resident was not eating meals, and staff interviews revealed a lack of communication and action regarding the resident's nutritional needs. Resident #13, with moderately impaired cognition and a history of depression and dementia, also experienced significant weight loss. The care plan included interventions for dysphagia and a mechanically altered diet, but the resident's weight continued to decline. The resident did not receive prescribed supplements on multiple occasions due to unavailability, and there was a lack of documentation regarding the weight loss in provider notes. Interviews indicated that the resident was not given meal options or sufficient encouragement to eat, contributing to the ongoing weight loss. Residents #18 and #34 were also affected by the facility's failure to provide ordered dietary supplements. Both residents had numerous instances in April where their supplements were marked as unavailable. The Assistant Director of Nursing acknowledged issues with back-ordered supplements and delays due to changes in suppliers. This lack of availability contributed to the residents not receiving necessary nutritional support, further highlighting the facility's deficiencies in managing residents' nutritional needs.
Inconsistent Access to Resident Funds
Penalty
Summary
The facility failed to ensure a process was in place to allow consistent access to resident funds outside of business hours for five residents who participated in the trust fund. During a review of facility documents, it was revealed that these residents utilized the trust fund. When queried, the Business Office Manager (BOM) stated that she would provide funds to residents if they asked. However, the Administrator acknowledged that money had not been consistently available 24 hours a day, although there had been some access on weekends. The facility's policy on the protection of resident funds indicated that residents should have access to their money in a reasonable time and in the form requested, but this was not consistently implemented.
Inadequate Staffing Leads to Multiple Care Deficiencies
Penalty
Summary
The facility failed to provide adequate staffing, resulting in several deficiencies affecting the care of multiple residents. Resident #19, who had moderately impaired cognition and required assistance with transfers due to recent shoulder surgery, experienced a fall with injury. The incident occurred when a CNA was delayed in responding to the resident's call light due to attending to another resident, leading to Resident #19 attempting to transfer independently and falling. Resident #207, with intact cognition but dependent on staff for transfers, reported significant delays in receiving assistance for toileting needs. The resident experienced an incontinent episode after waiting several hours for a bedpan, highlighting the facility's inability to respond promptly to call lights due to insufficient staffing. Additionally, the resident noted that staff failed to inquire about toileting needs during meal delivery, further contributing to the incident. Other residents, such as Resident #10 and Resident #28, also reported long wait times for assistance, impacting their daily living activities. Resident #10, who used a wheelchair and required assistance for transfers, often remained in bed due to delays in staff response. Resident #28, with intact cognition, missed several scheduled showers due to staffing issues, as confirmed by the Assistant Director of Nursing. Furthermore, Resident #12, with severely impaired cognition, was observed struggling to eat without receiving the necessary assistance and cueing from staff, despite being present in the dining area.
Dietary Service Deficiency in Meal Preparation
Penalty
Summary
The facility failed to ensure that residents receiving mechanical soft and pureed diets were served meals in accordance with the prescribed menu. Specifically, 18 residents on a mechanical soft diet did not receive the correct meal portions as outlined in the Week 2 Tuesday Menu, which specified servings of beans, ground meat, soft garlic bread, and vegetables. Additionally, 6 residents on a pureed diet did not receive pureed bread as required by the menu. The Dietary Manager acknowledged these discrepancies during the meal service. The Dietary Manager was observed preparing meals by cutting hot dogs into chunks and processing them to a ground consistency, then combining them with baked beans without measuring the total volume of the mixture. This resulted in an excess of over 5 servings of food after serving the mechanical soft diet meals. Furthermore, the pureed diet meals were served without the required pureed bread. The facility's policy for mechanically grinding food was not followed, as it directed staff to measure the total volume of food and divide it by the original number of servings, which was not done in this instance.
Inadequate Kitchen Sanitation and Infection Control
Penalty
Summary
The facility failed to maintain adequate kitchen sanitation and infection control measures during food service, as observed during a kitchen tour and meal service. The dishwashing machine was found to be operating at a wash temperature of 108 degrees Fahrenheit, significantly below the required 155 degrees Fahrenheit, and lacked testing strips to verify its functionality. The machine also had a heavy buildup of a white substance and black stains on the surrounding floor. Additionally, the handwashing sink in the kitchen was cold to the touch, and there was a significant accumulation of dust and food debris in various areas, including the shelf above the stove burners, the fire suppression system, and the microwave. During the noon meal service, further deficiencies were noted, including the continued use of the cold handwashing sink by staff, and the presence of food smears and dust in the kitchen. The Dietary Manager was observed wearing gloves while touching various surfaces and items, including her facial mask, and then serving food and drinks to residents without changing gloves, indicating a failure to follow proper infection control protocols. These observations highlight significant lapses in maintaining sanitary conditions and preventing cross-contamination in the facility's food service operations.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident with severely impaired cognition, as observed during two meal times. The resident, who required setup assistance and occasional cues, was left unassisted during lunch. Despite having a built-up utensil and pureed food, the resident did not eat and was not provided with encouragement or assistance by the staff. Observations noted the resident with eyes closed and arms crossed, and later attempting to eat with the spoon upside down, indicating a lack of proper assistance. During breakfast, the resident was observed sitting alone with spilled liquid on her lap and dripping to the floor. Despite the presence of staff, the resident was not assisted and continued to struggle with eating, using the handle of her adaptive fork to lick food. The resident remained unassisted for a significant period, highlighting a failure in providing timely assistance and maintaining the resident's dignity during meals.
Failure to Accommodate Resident's Bathroom Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident #16, by not individualizing the physical space of the resident's bathroom to ensure independent functioning, dignity, and well-being. Resident #16, who has an acquired absence of the left leg above the knee, pain in the right shoulder, and chronic obstructive pulmonary disease, was assessed to have intact cognition with a BIMS score of 14 out of 15. The resident required supervision or touching assistance for oral hygiene but was able to complete oral hygiene independently and took care of his dentures himself. After moving to a new room on December 5, 2023, the resident reported issues with the bathroom being too small to reach the sink, which was documented in an IDT Resident Care Conference note on December 7, 2023. However, there was no further documentation of any solutions discussed regarding the resident's bathroom concern. On April 29, 2024, the resident expressed dissatisfaction with the bathroom, demonstrating that he could not get within one foot of the sink, making the faucets and sink basin unreachable. The Assistant Director of Nursing (ADON) acknowledged that the bathrooms were not very large and sometimes wheelchairs did not fit, but she was unaware of any resident, including Resident #16, being unable to access the sink. The facility's policy on Accommodation of Needs, dated December 1, 2023, stated that reasonable accommodations would be made for individual needs and preferences, yet this was not reflected in the actions taken for Resident #16.
Failure to Provide Meal Options to Cognitively Intact Resident
Penalty
Summary
The facility failed to provide a resident with meal options, violating the resident's right to self-determination and choice. Resident #10, who was cognitively intact as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, did not receive a menu or meal options despite being on a regular/general diet with specific texture and consistency requirements. The resident expressed dissatisfaction, stating that he was not given choices because of his diabetes and that no one asked him what he wanted to eat. Interviews with staff revealed a lack of communication and oversight regarding the resident's meal preferences. The Dietary Manager admitted that Resident #10 did not receive a menu or options, mistakenly believing he did not want one. The Assistant Director of Nursing (ADON) confirmed that the resident had not received a menu during her tenure, attributing it to a period when the resident was very sick and did not choose options. Despite the resident's improved condition, the practice of offering a menu was not reinstated. The facility's policy on resident self-determination emphasized the resident's right to make choices about significant aspects of their life, which was not upheld in this case.
Failure to Notify Resident of Medicare Coverage Termination
Penalty
Summary
The facility failed to notify a Medicare Part A beneficiary, identified as Resident #8, of the termination of their coverage. This deficiency was identified through a clinical record review, staff interview, and policy review. The Beneficiary Notice-Residents discharged With the Last Six Months form indicated that Resident #8 was discharged from Medicare Part A on January 19, 2024. However, during an email correspondence on May 2, 2024, the Assistant Director of Nursing (ADON) admitted that the facility could not locate a discharge notice for Resident #8. The ADON also mentioned that at the time of the discharge, the facility had a different Social Services Director. According to the facility's policy on Beneficiary Notices, effective April 15, 2018, the facility is required to notify beneficiaries when their skilled nursing services and/or therapy services are ending and inform them of their right to request an appeal.
Deficiencies in Staff Background Checks and Training
Penalty
Summary
The facility failed to ensure that staff background checks were completed prior to the hire date for one of five staff members reviewed, and also failed to ensure that the dependent adult abuse mandatory reporter training was current for another staff member. Specifically, Staff C, an RN, was hired on 10/26/23, but her background check was not completed until 4/29/24. Additionally, Staff D, a CNA, did not have documentation of the required mandatory reporter training, despite being hired on 11/8/22. During an interview, the Administrator confirmed that the expectation was for background checks to be completed before hiring and for mandatory reporter training to be current. The facility's abuse policy mandates background checks and training on abuse prevention, identification, and reporting requirements at the time of hire, annually, and as needed.
Inaccurate MDS Coding for Medications and Catheter Use
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) coding for several residents, leading to discrepancies in medication and treatment documentation. For Resident #3, the MDS assessment indicated the use of an anticoagulant, but the February 2024 Medication Administration Record (MAR) did not document the administration of such medication. Similarly, Resident #46's MDS assessment also indicated anticoagulant use, yet the March 2024 MAR lacked corresponding documentation. The Assistant Director of Nursing (ADON) acknowledged the need for accurate MDS coding and mentioned a misunderstanding regarding the classification of medications like aspirin as anticoagulants. Additionally, the facility failed to accurately document the presence of a Foley catheter for Resident #11. The MDS assessment indicated the resident was always incontinent and did not have an indwelling catheter, despite hospice documentation confirming the presence of a Foley catheter. The ADON confirmed the oversight in documentation and coding. Furthermore, Resident #18's MDS assessment failed to reflect the administration of an antidepressant, despite a physician's order and MAR documentation showing daily administration of Mirtazapine for depression. The ADON acknowledged that Mirtazapine should have been coded as an antidepressant on the MDS.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and professional standards for three residents. For Resident #11, who has severely impaired cognition and diabetes, insulin was administered without clear parameters for when to hold the medication. The resident's insulin was held on several occasions based on blood sugar levels, but the facility lacked specific guidelines for these decisions. Staff interviews revealed inconsistent practices and reliance on nursing judgment without proper physician notification. Resident #18, who rarely understands, was prescribed Levetiracetam, an anticonvulsant medication, but the care plan did not address its use. The medication was not available on multiple occasions, and there was a lack of documentation explaining why doses were missed. The Assistant Director of Nursing acknowledged the absence of a backup supply and the need for a stat delivery from the pharmacy, which was not utilized in a timely manner. For Resident #50, who has intact cognition and a diagnosis of COPD, the facility failed to ensure proper administration of a steroid inhaler. The resident did not rinse and spit after using the inhaler, as required. Additionally, the medication orders for potassium and isosorbide mononitrate lacked dosages, leading to uncertainty among staff about the correct administration. Interviews with staff and the Interim DON highlighted the oversight in confirming medication orders and the lack of adherence to special instructions for inhaler use.
Deficiencies in ADL Assistance and Care
Penalty
Summary
The facility failed to consistently provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in care. Resident #29, who has a self-care deficit due to multiple medical conditions including quadriplegia and a below-knee amputation, was observed with long, jagged fingernails and facial hair, indicating a lack of grooming care. Despite the care plan specifying assistance with bathing and grooming, the resident was not shaved or had their nails trimmed as required. Staff interviews revealed confusion about responsibilities for nail care and shaving, with the shower aide and CNAs expected to perform these tasks. Resident #12, with severely impaired cognition, was observed during meal times without receiving the necessary assistance and cueing for eating. Despite being assessed as independent for eating, the resident required setup assistance and encouragement, which was not provided. Observations showed the resident struggling to eat, with food and liquid spilled on their lap, and no staff intervened to assist during the observed meal times. Resident #28, who has intact cognition but requires assistance with bathing, reported missing several showers over the year, including a two-week period without a shower. Documentation confirmed gaps in bathing assistance, with the resident not receiving the scheduled two baths per week. The Assistant Director of Nursing acknowledged that showers were not consistently completed, although this was not attributed to staffing issues. The lack of adherence to care plans and inconsistent documentation contributed to the deficiencies in providing adequate care for these residents.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to deficiencies in documentation and infection control practices. Resident #11, who had severely impaired cognition, was observed with a Foley catheter, but the facility's documentation, including the Minimum Data Set (MDS) assessment and Medication Administration Record (MAR), did not reflect the presence of the catheter. The Assistant Director of Nursing (ADON) acknowledged the oversight, noting that the resident's family had decided to place the resident on hospice care, which necessitated the catheter. However, the facility's policy on catheterization did not address the specific issues observed. Resident #19, with moderately impaired cognition, was observed with catheter tubing touching the ground while seated in a wheelchair, which poses an infection control risk. The Care Plan and Physician Orders for this resident lacked documentation of an indwelling catheter. Interviews with Certified Nurse Aides (CNAs) and the ADON confirmed that catheter tubing should not touch the floor and should be secured to prevent urine backflow. The facility's failure to ensure proper catheter placement and documentation for both residents highlights significant lapses in care and infection control practices.
Duplicate Opioid Orders for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically by having two active orders for the same opioid medication, hydrocodone/acetaminophen, for a resident reviewed for pain management. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS) exam, was diagnosed with multiple sclerosis and had several pressure ulcers at different stages upon admission. The care plan included administration of pain medications as per orders to manage the resident's comfort, particularly due to the presence of pressure ulcers and the associated pain. The physician orders revealed two separate prescriptions for hydrocodone/acetaminophen, one for 2 tablets every 6 hours as needed and another for 1 tablet every 6 hours as needed. The April Medication Administration Record (MAR) documented instances where both orders were administered within the same 6-hour period, indicating a failure to adhere to the prescribed time frame. Interviews with staff, including a registered nurse and the Assistant Director of Nursing, confirmed awareness of the duplicate orders and the need for change. The facility's medication administration policy emphasized the importance of administering medications according to the orders, including verifying the right medication, dosage, time, and method before administration.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) for two residents receiving psychotropic medications. Resident #28, who had intact cognition with a BIMS score of 15, was prescribed Trazadone for depression and insomnia. Despite a pharmacist's recommendation for a GDR, which the prescriber agreed to, the facility did not document any reduction in the medication dosage. The Assistant Director of Nursing (ADON) initially believed the reduction had occurred but later admitted the GDR was missed. Resident #13, with severely impaired cognition and a BIMS score of 6, was prescribed Duloxetine for depression. A pharmacist recommended a GDR from 40 mg to 30 mg, which the prescriber agreed to in November. However, the reduction was not implemented until January, as the medication administration record continued to list the dosage as 40 mg. The ADON was unaware of the delay and acknowledged that the GDR should have been implemented earlier. The facility's policy on psychotropic medications emphasizes the necessity of GDRs unless clinically contraindicated.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to offer bedtime snacks to two residents who desired them, despite their expressed preferences and the facility's policy. Resident #28, who has diagnoses including depression, diabetes, and non-Alzheimer's dementia, reported that staff did not offer him bedtime snacks, which he would like to receive. Documentation for April 2024 showed multiple dates where there was no record of snacks being offered to him. Similarly, Resident #46, with diagnoses of anxiety, depression, and muscle weakness, stated that she no longer received bedtime snacks, which were previously provided around 7:30 p.m. Documentation also showed numerous dates where snacks were not offered. Interviews with staff revealed that the failure to provide snacks was due to a combination of factors, including staff being too busy to offer snacks and a lack of available snacks following a change in the facility's corporate ownership. Staff members reported that they sometimes had to purchase snacks themselves due to shortages. The Dietary Manager acknowledged issues with snack availability due to budget considerations under the new management, although improvements were noted. The facility's policy, revised in July 2023, stated that all residents should be offered a bedtime snack, which was not adhered to in these cases.
Repeated Deficiencies in QAPI Process and Resident Care
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) process, resulting in multiple repeat deficiencies identified during the current recertification and complaint survey. These deficiencies were previously identified in surveys conducted over the last 19 months. The facility, with a census of 58 residents, received citations for dignity, professional standards not met, and food procurement, storage, preparation, and sanitation without actual harm. Additionally, a complaint survey revealed a harm level citation for accident hazards/supervision and a no actual harm citation for activities of daily living/maintain abilities. During a subsequent complaint and incident revisit survey, the facility received no actual harm level citations for accident hazards/supervision, dignity, and QAPI program/good faith effort. The current recertification survey resulted in a harm level deficient practice for accident hazards/supervision and no actual harm level citations for dignity, QAPI program/good faith effort, activities of daily living/maintain abilities, meeting professional standards, and food procurement, storage, preparation, and sanitation. The facility's QAPI plan, dated 9/12/13, outlined guidelines and performance improvement plans, but the repeated citations indicate a failure to effectively address and sustain improvements in these areas.
Failure to Ensure Adequate Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to ensure a surety bond was in place to cover the total amount of personal funds in the resident trust account for five residents who utilized the trust fund. The facility had a census of 58 residents. A document titled 'Residents who use the trust' revealed that five residents utilized the trust fund. The surety bond provided by the facility was dated 6/23/23 and had an amount of $40,000. However, on 5/02/24, the facility's Administrator confirmed that the total amount of resident funds exceeded the facility's surety bond. The facility's policy on the protection of resident funds required a surety bond on the cumulative total of all resident trust fund balances, which was not met in this case.
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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