Grandview Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oelwein, Iowa.
- Location
- 800 Fifth Street Se, Oelwein, Iowa 50662
- CMS Provider Number
- 165340
- Inspections on file
- 20
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Grandview Healthcare Center during CMS and state inspections, most recent first.
Failure to obtain consent and provide psychotropic medication education: A resident with late onset Alzheimer’s Disease was started on multiple psychotropic meds, including an antidepressant, antipsychotic, antianxiety med, and another antidepressant, but the EHR did not show consent before initial administration. There were also no progress notes or assessments documenting education on side effects, risks vs benefits, or offering alternative treatments before the meds were given, despite facility policy requiring informed consent and discussion of nonpharmacological approaches and medication alternatives.
Incomplete Comprehensive Care Plan Development: A resident’s admission MDS triggered multiple CAA areas, but only one of the identified care areas was documented on the comprehensive care plan by the required timeframe. The MDS Coordinator said the resident was missed on the team schedule, and the interim DON stated baseline care plans were expected within 48 hours and comprehensive care plans within 7 days of the admission MDS completion.
Multiple residents did not receive their medications within the required 1-hour window before or after the scheduled dosing time, as confirmed by medication administration audits and staff interviews. Facility policy and DON expectations were not followed, resulting in repeated late or early medication administration for several residents.
A resident with quadriplegia and contractures did not consistently receive prescribed passive range of motion exercises or have hand splints and palm protectors applied as recommended by therapy. Observations showed splints were often not in use, documentation was inconsistent, and staff were unclear about program frequency and responsibilities. The care plan lacked clear instructions, and there was no facility policy for restorative nursing, resulting in failure to provide and document the required restorative care.
A nurse failed to prime an insulin pen and did not hold it at the injection site for the recommended duration while administering insulin to a resident with diabetes. Other nursing staff and facility policy confirmed that the expected procedure is to prime the pen and hold it in place to ensure proper medication delivery.
A resident with chronic wounds and an MDRO infection received wound care from an LPN who failed to place a barrier between the resident's foot and the bed linen, allowing the wound to come into direct contact with the linen. Both the LPN and DON acknowledged the omission, and the bed linens were not changed immediately after the procedure, contrary to facility infection control guidelines.
A resident with edema did not receive physician-ordered tubi-grip compression sleeves due to staff unawareness and incorrect documentation of refusals. The facility lacked the correct size in stock, leading to improper treatment. The resident reported not having the sleeves since a therapy company change, and staff confirmed their absence on multiple occasions.
Two residents with significant weight loss were not served the correct puree portion sizes as prescribed. Despite preparation instructions, dietary staff failed to provide the appropriate amount of food, resulting in both residents receiving less than required. Observations showed that the residents consumed all their meals, indicating insufficient portions.
The facility failed to complete SCSA MDS assessments within the required time frame for two residents in hospice care. One resident's MDS was completed 21 days after a significant change, exceeding the 14-day requirement. Another resident's MDS was not finalized by the required date. Staff G confirmed the lack of an MDS policy and misunderstanding of time requirements.
The facility failed to accurately complete the MDS for three residents, leading to deficiencies in documenting anticoagulant medication and PASRR conditions. One resident was incorrectly documented as taking anticoagulant medication, while two residents had inaccurate PASRR documentation regarding their mental health diagnoses. These errors were confirmed by staff, who admitted to not following the RAI manual's guidance.
The facility failed to properly coordinate and submit PASRRs for two residents, leading to deficiencies in their care plans. One resident's PASRR was not resubmitted despite new diagnoses, while another's PASRR omitted significant diagnoses and medications. Staff interviews revealed a lack of awareness and verification of PASRR accuracy.
Failure to Obtain Consent and Provide Psychotropic Medication Education
Penalty
Summary
The facility failed to ensure that Resident #33 was fully informed and understood the resident’s health status, care, and treatments related to psychotropic medications. Resident #33’s admission MDS, dated 3/9/26, documented late onset Alzheimer’s Disease, and the resident was admitted to the facility on 3/2/26. The MAR for March 2026 showed orders for Escitalopram starting 3/3/26, Quetiapine starting 3/2/26, Lorazepam starting 3/4/26, and Trazodone starting 3/25/26. A review of the EHR did not reveal consent obtained for any of these medications before initial administration. The record also did not show progress notes or assessments documenting education about the side effects, risks versus benefits of psychotropic medications, or the offering of alternative treatments before the medications were given. The Interim DON stated staff were to contact the family and discuss side effects before any new psychotropic medication was started, and that for new residents medication education was a priority before the first dose was administered. The facility policy required documentation of nonpharmacological approaches, assessment of benefits, risks, and treatment goals, informed consent before initiating or increasing psychotropic medications, and education about benefits, risks, alternatives, and black box warnings.
Incomplete Comprehensive Care Plan Development
Penalty
Summary
The facility failed to develop and implement a timely, comprehensive care plan for Resident #33 after the admission MDS assessment triggered nine CAA categories. The facility identified six areas to be addressed in the Comprehensive Care Plan: Cognitive Loss/Dementia, Communication, Urinary incontinence, Behavioral Symptoms, Nutritional Status, and Psychotropic Drug Use. The MDS documented a CAA completion date and care plan completion date of 3/13/26, and the RAI manual required the comprehensive care plan to address the triggered CAA findings within 7 days of the CAA completion date. A record review on 4/13/26 found that only one of the six identified CAA areas was documented on the Comprehensive Care Plan. The admission MDS was dated 3/9/26 and documented an admission date of 3/2/26. On 4/15/26, the MDS Coordinator stated the resident was missed on the team’s schedule and that the team was looking into how that happened. The interim DON stated her expectation was for baseline care plans to be completed within 48 hours of admission and comprehensive care plans to include all needed items within 7 days of the admission MDS being completed. The facility policy stated baseline care plans should be in place within 48 hours and person-centered care plans should be completed after the comprehensive assessment.
Failure to Administer Medications Within Prescribed Time Frame
Penalty
Summary
The facility failed to administer medications within the required time frame of 1 hour before to 1 hour after the scheduled dosing time for five residents. Clinical record reviews, policy review, and staff interviews revealed that all five residents had multiple instances over a 15-day period where medications were given outside of this two-hour window. Specifically, each resident had medications scheduled up to four times daily, and the Medication Administration Audit Reports showed consistent deviations from the prescribed administration times for nearly every day reviewed. Facility policy, last revised in May 2023, directs staff to administer medications in accordance with physician orders and within the specified time frame. During an interview, the DON confirmed the expectation that medications should be given within the 1-hour window before or after the scheduled time. Despite this, the audit reports for all five residents demonstrated repeated failures to meet this standard, as medications were not administered as ordered by the physicians.
Failure to Implement and Document Restorative Nursing Program for Resident with Contractures
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care to maintain or improve range of motion (ROM) and mobility for a resident with significant functional impairments. The resident, who was in a persistent vegetative state with quadriplegia and contractures, was dependent on staff for all self-care and mobility needs. Occupational therapy discharge recommendations specified daily passive range of motion (PROM) exercises for both upper and lower extremities, as well as a hand splint program with splints to be worn two hours on and two hours off, with palm protectors used when splints were not in place. Despite these recommendations, observations revealed that the resident was frequently found in bed without hand splints or palm protectors in use, and the splints were often seen lying unused on the window ledge. Documentation in the electronic medical record was inconsistent, with several days lacking any record of the restorative nursing program (RNP) being completed, and some staff reporting that they marked the resident as refusing the program when, in fact, they had not attempted to apply the splints due to lack of training. Interviews with staff indicated confusion about the frequency and responsibility for the RNP, with some staff unaware of the specific therapy recommendations or unsure who was responsible for carrying out the program on days when the primary restorative staff member was not present. The care plan for the resident lacked clear direction regarding the RNP and the use of hand splints, and there was no facility policy or procedure for restorative nursing. The task record and treatment administration record (TAR) did not consistently reflect the use of hand splints or palm protectors, and nursing staff did not always review therapy discharge recommendations when setting up the RNP. Family members also reported never seeing the hand splints in use during visits. These actions and omissions resulted in the facility's failure to implement and document the prescribed restorative care program for the resident as recommended by therapy.
Failure to Follow Insulin Pen Administration Protocols
Penalty
Summary
A deficiency was identified when a nurse failed to follow manufacturer instructions for administering insulin using an insulin pen for a resident with diabetes mellitus. The nurse removed the resident's Lantus Glargine pen from the medication cart, checked the physician's order, and set the pen to the prescribed dose of 45 units. However, the nurse did not prime the pen with two units of insulin as required by the manufacturer's guidelines. The nurse then injected the insulin into the resident's lower right abdominal quadrant, pushed the button to administer the dose, and withdrew the pen without holding it in place for the recommended 10 seconds. Interviews with other nursing staff revealed that the expected practice is to prime the insulin pen with one or two units until insulin is visible at the needle tip, then administer the prescribed dose and hold the pen at the injection site for several seconds to ensure full delivery. The facility's policy, consistent with manufacturer instructions, directs staff to prime the pen and hold it in place for 6-10 seconds during administration. The Director of Nursing confirmed that staff are expected to follow these procedures. The failure to prime the pen and hold it for the appropriate duration constituted a significant medication error for the resident.
Failure to Use Barrier During Wound Care Results in Infection Control Deficiency
Penalty
Summary
A deficiency occurred when staff failed to place a barrier between a resident's foot and the bed linen during wound care treatment, as observed by surveyors. The resident had a history of coronary artery disease, peripheral vascular disease, diabetes mellitus, and a multi-drug-resistant organism (MDRO), and was being treated for two unstageable pressure ulcers on the left foot, one of which was infected. The treatment orders required cleansing, application of betadine, and covering the wounds with dressings, but did not specify the use of a barrier between the wound and bed linen. During the observed wound care procedure, an LPN donned appropriate personal protective equipment and prepared the treatment supplies on a barrier on the treatment cart. However, while performing the wound care, the LPN allowed the resident's left foot, which had open wounds and drainage, to rest directly on the bed linen multiple times without placing a barrier underneath. The LPN acknowledged after the procedure that a barrier should have been used to prevent cross contamination. The DON also confirmed that no barrier was used during the treatment. Additionally, the resident reported that the bed linens were not changed after the wound care procedure, and a CNA confirmed that linens are typically changed once per week, with the resident's linens changed the morning after the observed treatment. Facility policy required the use of standard precautions and enhanced barrier precautions for residents with chronic wounds, and contaminated linen should be bagged at the time of use. The failure to use a barrier and to change potentially contaminated linens was inconsistent with these guidelines.
Failure to Administer Physician-Ordered Treatment
Penalty
Summary
The facility failed to administer a physician-ordered treatment for a resident who required tubi-grip compression sleeves due to edema. The resident, who had no cognitive impairment and required total assistance for transfers, was observed without the prescribed tubi-grip sleeves on multiple occasions. The resident's care plan and physician order specified the use of size D tubi-grip from fingers to elbow and size J from elbow to shoulder, to be worn during the day and removed at night. However, the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented frequent refusals of the treatment, and staff interviews revealed a lack of awareness and adherence to the order. Staff members, including CNAs and CMAs, were either unaware of the order or incorrectly documented the resident's refusal without verifying compliance. The facility also failed to maintain an adequate stock of the required size J tubi-grip, leading to the use of an incorrect size as a temporary measure. The resident reported not having the tubi-grips since a change in therapy companies, and staff confirmed the absence of the sleeves on several occasions. The deficiency was further highlighted by the lack of communication and coordination among staff, as well as the failure to ensure the availability of necessary supplies.
Failure to Serve Correct Puree Portion Sizes
Penalty
Summary
The facility failed to serve the correct puree portion size for two residents, both of whom experienced significant weight loss over the past six months. Resident #26, with severe cognitive loss and a history of non-Alzheimer's dementia, was on a mechanically altered diet due to significant weight loss. The resident's weight dropped from 231.4 pounds to 206.5 pounds over six months, indicating an 11.4% weight loss. Similarly, Resident #19, with moderate cognitive loss and diagnoses of aphasia and paranoid schizophrenia, also required a mechanically altered diet. This resident's weight decreased from 264.5 pounds to 231.1 pounds, reflecting an 11.9% weight loss over the same period. The deficiency occurred when the dietary staff failed to follow the prescribed portion sizes for the pureed diet. During meal preparation, Staff B prepared six servings of a pureed ham and cheese sandwich, using a chart to determine the correct portion size. The chart indicated that each resident should receive two #8 scoops and one #30 scoop of the puree. However, Staff C and Staff D did not adhere to these guidelines. Staff C served only one #8 scoop to Resident #26 and another resident, while Staff D used only the #30 scoop for Resident #19, resulting in both residents receiving less than the required portion. Observations revealed that both residents consumed all of their meals, with Resident #26 continuing to scrape and lick his empty bowl, indicating insufficient food. Staff B confirmed that the correct portion sizes were not served, as the #30 scoop was not used. The facility's procedure for determining portion sizes was not followed, leading to the deficiency in serving the appropriate amount of food to residents on pureed diets.
Failure to Timely Complete Significant Change MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to complete Significant Change in Status (SCSA) Minimum Data Set (MDS) assessments within the required time frame for two residents who were reviewed for hospice care. Resident #22 had a physician order for hospice referral dated 4/29/24, but the MDS was not completed until 5/21/24, which was 21 days after the determination of a significant change. According to the Resident Assessment Instrument (RAI) guidelines, the MDS should have been completed no later than 14 days after the determination of a significant change in the resident's status. Staff G, the Resident Care Coordinator, confirmed the dates and acknowledged the lack of an MDS policy, relying solely on the RAI for guidance. Similarly, Resident #29 was admitted into hospice care on 6/11/24, with the family signing the Hospice Election Statement on the same day. However, the MDS assessment reference date was 6/21/24, and the assessment was not completed by the required date of 6/24/24. During an interview, Staff G expressed a lack of understanding regarding the time requirements for completing the significant change assessment as per the RAI manual. This oversight resulted in the MDS not being signed, finalized, and locked within the required time frame.
Inaccurate MDS and PASRR Documentation
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for three residents, leading to deficiencies in the assessment process. For one resident, the MDS inaccurately documented the use of anticoagulant medication, while the physician's orders only included clopidogrel, an antiplatelet medication. This discrepancy was confirmed by the Co-Director of Nursing, who acknowledged that clopidogrel should not have been coded as an anticoagulant. The facility lacked a specific MDS policy and relied on the Resident Assessment Instrument (RAI) and an MDS Drug Class Index, which correctly listed clopidogrel as an antiplatelet medication. Additionally, the facility failed to accurately document the Pre-Admission Screening and Resident Reviews (PASRR) for two residents. One resident's PASRR indicated a diagnosis of schizoaffective disorder, bipolar type, but the MDS incorrectly marked the resident as not having a serious mental illness. Another resident's PASRR documented a diagnosis of bipolar I disorder and major depressive disorder, but the MDS failed to reflect the major depression diagnosis. These inaccuracies were confirmed by the staff responsible for completing the MDS, who admitted to not following the RAI manual's guidance for coding PASRR conditions.
Failure to Ensure Accurate PASRR Submission for Residents
Penalty
Summary
The facility failed to ensure proper coordination and submission of Pre-admission Screening and Resident Review (PASRR) for two residents, leading to deficiencies in their care plans. Resident #19 was initially approved for a short-term 60-day stay in 2018, with new diagnoses documented in her medical record. However, the facility did not resubmit her PASRR for review of needed services. During interviews, staff members, including a social worker, an LPN, and the administrator, were unaware of the short-term PASRR requirement for Resident #19. It was only on 7/3/24 that a new PASRR was received for this resident. For Resident #22, the facility failed to accurately complete the PASRR prior to admission, omitting significant diagnoses and medications. The admission MDS documented major depressive disorder and psychotic disorder with delusions, and the resident was prescribed quetiapine, Namenda, and lorazepam upon admission. However, the PASRR Level 1 completed on 8/31/23 did not reflect any known or suspected mental health diagnoses, and only included lorazepam and Namenda as medications. An LPN admitted during an interview that she does not verify PASRRs for accuracy regarding diagnoses and medications.
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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