Good Samaritan - George
Inspection history, citations, penalties and survey trends for this long-term care facility in George, Iowa.
- Location
- 324 First Avenue North, George, Iowa 51237
- CMS Provider Number
- 165247
- Inspections on file
- 17
- Latest survey
- August 21, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Good Samaritan - George during CMS and state inspections, most recent first.
The facility did not meet staffing requirements due to inaccurate PBJ data submission, which showed excessively low weekend staffing despite reports that nurse and CNA schedules were consistent throughout the week. The Administrator was unaware of the data submission process and confirmed the absence of a PBJ policy, while the DON attributed the discrepancy to the use of corporate staffing pool personnel.
Staff failed to provide accurate meal portions to residents, with pureed meals being served in incorrect amounts and without proper measurement. Some residents received only half portions without care plan authorization, and staff relied on visual estimation rather than precise measurement, contrary to facility policy and dietary orders.
Surveyors found that food items in the kitchen and refrigerator were not labeled, dated, or stored according to facility policy and professional standards. Open containers of cereals, syrups, dairy products, juices, and dressings were observed without required labels or open dates, and some items were improperly stored, such as uncovered cake and a box of oranges on the floor. Interviews with the Dietary Manager and Administrator confirmed these practices did not meet expectations.
A resident with severe cognitive impairment was transferred to the hospital twice, and on both occasions, the facility failed to obtain the required signature from the resident's representative on the bed hold notice, relying only on verbal authorization and not following policy to mail the notice if the representative was not present.
A resident with multiple medical conditions who used a CPAP machine nightly did not have current CPAP orders or settings entered into the electronic chart, and the use of the CPAP was not included in the care plan. Staff interviews confirmed the omission occurred during a change in responsibility, and facility policy requiring documentation and care planning for respiratory devices was not followed.
A CNA allegedly slapped a cognitively impaired resident during care, but the incident was not reported immediately, allowing the CNA to continue working with residents. The facility's policy requires immediate reporting of abuse, but staff failed to follow this protocol, delaying the investigation and exposing residents to potential harm.
The facility failed to serve full food portions and did not consistently fill and empty scoop utensils during meal preparation. Meals were partially switched due to improperly thawed meat, and incorrect scoop sizes led to inconsistent food portions for residents. The facility lacked a policy on portion size and scoop usage, and the Administrator expected correct food servings as per the menu.
The facility failed to submit accurate staffing reports for the CMS PBJ Staffing Data Report, showing excessively low weekend staffing and insufficient licensed nursing coverage for four or more days. The issue arose from incorrect payroll data, as employees were not punched in for breaks, leading to inaccurate reporting.
A facility failed to ensure proper hand hygiene during urinary catheter care for a resident. A CNA was observed changing gloves multiple times without performing hand hygiene in between, contrary to the facility's policy. The Nurse Educator present acknowledged the oversight.
A resident with severe cognitive impairment was physically abused by a CNA during bedtime care, as the CNA became frustrated and swatted the resident's arm. The incident was witnessed by another CNA but was not reported immediately, delaying intervention. The facility's policy on abuse and neglect was not followed, as the incident was only reported to the DNS several days later, allowing the involved staff member to continue working with residents.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment within the required 2-hour timeframe. The incident, where a CNA allegedly swatted the resident's arm during care, was reported to the DNS on June 27, but the facility delayed notifying the authorities until later that day, violating state regulations.
Failure to Accurately Report Staffing Data in PBJ Submission
Penalty
Summary
The facility failed to meet staffing requirements in all metrics as evidenced by the CMS Payroll Based Journal (PBJ) Staffing Data Report for Fiscal Quarter 2, 2025, which showed excessively low weekend staffing data. The facility reported a census of 31 residents during this period. Staffing schedules for nurses and CNAs were reportedly similar for both weekdays and weekends, but the PBJ data submitted indicated otherwise. The Administrator stated he was unaware of how the corporate office submitted staffing data and confirmed there was no facility policy regarding PBJ. The Director of Nursing (DON) suggested the low weekend staffing data may have resulted from the use of corporate-supplied staffing pool personnel, but maintained that actual staffing levels did not differ between weekdays and weekends and that insufficient staffing did not occur during the quarter.
Failure to Serve Proper Meal Portions to Residents
Penalty
Summary
Facility staff failed to serve proper portion sizes to residents during meal service, as observed during a meal preparation and service. Staff A prepared pureed meals by combining multiple servings of meat, potatoes, roll, and gravy, as well as spinach, but did not accurately measure the portions according to the residents' dietary requirements. Instead of providing the prescribed two #8 scoops of the pureed mixture per resident, Staff A served only one scoop of each mixture to two residents, leaving extra food in the pan. When questioned, Staff A was unable to confirm the exact measurements used and admitted to estimating portion sizes based on visual cues rather than precise measurement. Additionally, approximately ten plates were served with smaller, unmeasured portions because residents reportedly requested half servings, but only one resident was care planned for half portions. Interviews with the Dietary Manager and review of facility policies confirmed that staff are expected to serve full portions unless otherwise ordered and documented in the care plan. The Dietary Manager acknowledged that Staff A should have served the correct portions and that only one resident was authorized for half portions. Facility policy also specifies that pureed foods should not be combined unless requested and documented, and that meals should be well-balanced and provide adequate nutrition. The Administrator confirmed that staff are required to serve proper amounts as ordered.
Failure to Store and Prepare Food Under Sanitary Conditions
Penalty
Summary
Surveyors observed multiple instances of improper food storage and preparation in the facility's kitchen. During an initial walkthrough, several open food items, including containers of Cheerios, rice cereal, raspberry syrup, oatmeal, and cornstarch, were found without labels or open dates. In the refrigerator, there were uncovered servings of cake, open cartons of liquid egg, heavy whipping cream, white milk, pitchers of orange and apple juice, thickened water, open containers of Greek yogurt past their expiration date, and various dressings and sauces, all lacking required labels or open dates. Additionally, a box of oranges was found sitting directly on the floor. These findings were in direct violation of the facility's policy, which requires opened or prepared foods to be placed in enclosed containers, labeled, dated, and stored properly. Interviews with the Dietary Manager and the Administrator confirmed that their expectations aligned with the facility's policy, specifically that dietary staff should date items when opened and ensure proper storage, including covering and labeling. The failure to follow these procedures was evident in the observed conditions, as numerous food items were not labeled, dated, or stored according to professional standards and facility policy. The facility had a census of 31 residents at the time of the survey.
Failure to Obtain Required Bed Hold Notice Signatures
Penalty
Summary
The facility failed to ensure that required bed hold notices were properly signed by the resident's representative when a resident with severe cognitive impairment was transferred out of the facility on two separate occasions. Clinical record review showed that the resident, who had diagnoses including hypertension, anemia, and arthritis, was hospitalized twice, and in both instances, the bed hold documentation only included verbal authorization from the resident's representative without obtaining the necessary signature. Facility policy requires that the Notice of Bed-Hold Policy be mailed if the family or representative does not come to the facility to receive a copy, but there was no evidence that this was done. Interviews confirmed that the signatures were missed and should have been obtained.
Failure to Document and Care Plan CPAP Use for Resident
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care for a resident who required nightly use of a continuous positive airway pressure (CPAP) machine. The resident, who had diagnoses including renal insufficiency, diabetes, and anemia, reported using a CPAP nightly. Observations confirmed the presence of a CPAP machine at the bedside, and a faxed physician's order for the device was present. However, the facility did not enter the CPAP order or its settings into the electronic chart, and the resident's care plan did not reflect the use of the CPAP machine. The Minimum Data Set (MDS) assessment also failed to indicate the resident's use of a non-invasive mechanical ventilator. Interviews with facility staff revealed that the omission occurred during a transition of responsibility from the Director of Nursing (DON) to the MDS Coordinator. Both the MDS Coordinator and the DON confirmed that the CPAP order and care plan documentation were missing. The facility's policy required provider orders for respiratory devices to be recorded and included in the care plan, but these steps were not followed for this resident.
Failure to Report Abuse Allegation Promptly
Penalty
Summary
The facility staff failed to report an allegation of abuse involving a Certified Nurse Aide (CNA) who allegedly slapped a resident on the upper arm. This incident occurred during bedtime care when the resident, who has severe cognitive impairment due to a stroke, hypertension, and depression, yelled out. The CNA became frustrated and swatted the resident's arm. Despite witnessing the event, the staff did not report it immediately, allowing the alleged perpetrator to continue working with other residents. The incident was not reported to the Director of Nursing Services (DNS) until several days later, when a CNA confided in another staff member about witnessing the abuse. The staff member who was informed did not report the incident immediately, citing distrust in the charge nurse on duty. It was only after further discussion with another staff member that the incident was finally reported to the DNS. The facility's policy requires immediate reporting of any suspected abuse to a supervisor, and the charge nurse is responsible for assessing the situation and ensuring the safety of residents by removing the alleged perpetrator from direct care. However, this protocol was not followed, resulting in a delay in addressing the abuse allegation and exposing residents to potential harm.
Removal Plan
- The local police, resident's physician, and family/responsible party were notified of the allegation. An initial report was made to DIAL within the expected two-hour time frame.
- Staff members who failed to report immediately received immediate education and re-did the Iowa required Dependent Adult Abuse course online. Corrective action was completed as well with both staff members.
- The social services manager interviewed all residents to determine if there were any concerns by residents of care and treatment by staff members. None were identified.
- Education on abuse and neglect for all staff regarding the treatment of residents and the importance of immediately notifying leadership and/or supervisor of any allegation so steps can be immediately taken to remove/separate suspected staff from residents. A quiz for comprehension was completed by staff. Education was completed with all staff prior to any staff working another shift.
- Administrator or designee will audit through abuse and neglect questionnaires 5 team members randomly to include all shifts daily to ensure staff education on abuse and neglect investigation and reporting.
- Audits will be taken to QAPI for further review and recommendations.
- Center leadership has continued to provide daily reminders to staff on the need to report immediately any suspected abuse and/or neglect.
- Center leadership, including the Director of Nursing, Administrator, and Social Services, have ensured that their phone numbers have been made available for all staff to place in their phones to ensure the ability to call them at all times.
- A Skills Fair was completed where continuing reminders and education were again provided.
Failure to Serve Correct Food Portions
Penalty
Summary
The facility failed to serve the full portions of food to residents and did not consistently fill and empty scoop utensils when preparing meals. The Dietary Manager (DM) reported that meals were partially switched due to meat not being completely thawed, leading to a replacement meal being served. During meal service, the DM did not completely fill and empty the scoop when serving corn and minced pork, resulting in two residents receiving 1.5 ounces more pork, while the last two residents did not receive full scoops. Additionally, the incorrect scoop size used for broccoli resulted in a resident receiving 2.5 ounces less broccoli. The facility did not provide a policy specifically related to portion size and usage of food scoops when plating food. The Administrator expected staff to serve the correct amount of food as per the menu.
Inaccurate Staffing Reports Due to Payroll Errors
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period of January 1 to March 31. The report indicated excessively low weekend staffing, with the facility failing to provide licensed nursing coverage 24 hours a day for four or more days within the quarter. Despite the staffing for nurses and Certified Nursing Assistants (CNAs) being scheduled similarly for weekdays and weekends, no issues were found for nursing coverage. The deficiency was attributed to incorrect payroll data, as employees were not punched in for breaks, leading to inaccurate reporting.
Failure in Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during urinary catheter care for a resident. During an observation, a Certified Nursing Assistant (CNA) donned personal protective equipment and retrieved a urine colander. The CNA placed the colander in the bathroom, removed and discarded gloves, but failed to perform hand hygiene before donning new gloves. The CNA then assisted the resident to sit in a recliner, again removed and discarded gloves without completing hand hygiene, and donned new gloves. The CNA continued to handle the resident's catheter drainage without performing hand hygiene between glove changes. The facility's policy, last revised in July 2024, instructed staff to perform hand hygiene after glove removal. The Nurse Educator present during the observation acknowledged the failure to perform hand hygiene after changing gloves.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who physically struck a resident. The resident, who had severe cognitive impairment due to a stroke, hypertension, and depression, was receiving bedtime care when the incident occurred. During the care, the resident yelled out due to discomfort from cold wipes, which led to the CNA becoming frustrated and swatting the resident's upper arm. This incident was witnessed by another CNA, who reported that the resident expressed pain by saying 'ouch' and questioned the action. Despite witnessing the event, the incident was not immediately reported to the Director of Nursing Services (DNS) or management, delaying appropriate intervention. The facility's policy on abuse and neglect, which emphasizes the residents' right to be free from abuse, was not adhered to in this case. The incident was only reported to the DNS several days later, on 6/27/24, after being confided to another staff member. Interviews with staff involved revealed that the incident was not immediately reported, and the resident's condition was not assessed for physical harm immediately following the event. The facility's failure to promptly report and address the incident allowed the staff member involved to continue working with residents, contrary to the facility's policy and the administrator's expectations.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 4, who had diagnoses of stroke, hypertension, and depression. On June 19, 2024, a Certified Nursing Assistant (CNA) allegedly swatted the resident's arm out of frustration during bedtime care. This incident was reported to the Director of Nursing Services (DNS) on June 27, 2024, at 10:20 p.m., but the facility did not submit a self-report to the authorities until 9:34 p.m. on the same day, which was beyond the 2-hour reporting requirement. The facility's policy mandates that any allegations of abuse, neglect, exploitation, or mistreatment be reported immediately, but not later than two hours after the allegation is made. Despite this policy, the DNS acknowledged the delay in reporting the incident to the state. The failure to adhere to the reporting timeline constitutes a deficiency in the facility's compliance with state regulations regarding the timely reporting of abuse allegations.
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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