Mercyone Centerville Medical Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerville,, Iowa.
- Location
- One St Joseph Drive, Centerville,, Iowa 52544
- CMS Provider Number
- 16E728
- Inspections on file
- 20
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Mercyone Centerville Medical Center during CMS and state inspections, most recent first.
A resident with end-stage COPD and on hospice care had an order for Morphine Sulfate 10 mg/5 ml, 1 ml (2 mg) PO q4h PRN for air hunger, but the pharmacy dispensed Morphine 20 mg/ml with labeling that directed 1 ml (20 mg) q4h PRN. Nursing staff accepted and administered the medication without verifying the concentration against the original order, relying instead on the bottle label, narcotic record, and an EMAR entry that only specified 1 ml without the milligram dose. An LPN gave one 20 mg dose for labored breathing and pain, and an RN later administered two additional 20 mg doses for air hunger, while another RN acknowledged that the usual two-nurse verification process at receipt was not followed. The ARNP and pharmacist later confirmed that the pharmacy had entered and dispensed the wrong concentration, and that the resident had received three doses at ten times the ordered amount, constituting a significant medication error.
The facility did not provide or document advance information to residents or their representatives regarding the risks and benefits of prescribed psychotropic medications. Multiple residents with conditions such as dementia, anxiety, depression, and other chronic illnesses received medications like antidepressants and antipsychotics without documented informed consent, as confirmed by staff interviews and record reviews.
Surveyors found 13 cartons of expired Glucerna creamy strawberry nutritional supplement stored with other supplement drinks in the kitchen. The expired product was overlooked during daily checks by dietary staff because no residents were currently using that flavor, despite facility policy requiring expired items to be discarded.
The facility did not notify the State LTC Ombudsman about the hospitalization and discharge of two residents, including one who was hospitalized and returned, and another who was discharged home with hospice. Documentation and staff interviews confirmed the lack of required notifications, and facility leadership was unaware of the notification requirement.
The facility did not complete federally required MDS assessments for two residents. One resident's quarterly MDS assessment was left incomplete, and another resident who was hospitalized and returned did not have the necessary discharge and reentry MDS assessments completed. The MDS Coordinator and DON acknowledged the lapses in timely completion of these assessments.
Two residents' care plans did not address all identified needs, including the use of diuretic and antidepressant medications and the risk of skin breakdown on the coccyx. One resident's care plan omitted guidance on monitoring for medication side effects, while another's did not include the presence of an open area on the coccyx, despite clinical documentation and facility policy requirements.
A resident's care plan was not developed within 7 days of the comprehensive assessment, and the required team of health professionals did not prepare, review, or revise the plan as mandated.
The facility did not consistently provide scheduled activities for residents, as many activities were canceled or not held when the Activity Director was assigned to CNA duties. Several residents with intact cognition and various medical conditions reported that activities were frequently missed, especially on weekends, and documentation confirmed limited participation over several months. Staff interviews supported that staffing shortages led to the cancellation of about 40% of planned activities, contrary to facility policy.
A resident with a history of receiving Pneumovax (PPSV23) did not have documentation of being offered a pneumococcal conjugate vaccine as recommended by CDC guidelines. Facility policy required nursing staff to screen, educate, and document immunization status, but this process was not followed for the resident, as confirmed by staff and record review.
Staff did not ensure a resident with moderate cognitive impairment was dressed appropriately for communal areas, bringing her to the dining room in a nightgown or with only a shirt and brief covered by a blanket. Staff also used double incontinent products instead of providing more frequent changes, contrary to proper care practices. These actions failed to uphold the resident's dignity and respect.
A resident who was unable to perform activities of daily living independently did not receive the necessary care and assistance from staff, resulting in unmet needs for support with ADLs.
The facility failed to properly assess and document skin impairments for a resident with dementia and diabetes, including lack of timely assessment and unauthorized bandage application by a CNA. Additionally, the facility did not include hospice services in care planning or communicate significant changes and medication orders for a resident receiving end-of-life care, resulting in discrepancies between facility and hospice orders and lack of documented collaboration.
Staff did not consistently wear required PPE, such as gowns and gloves, during wound and personal care for two residents on Enhanced Barrier Precautions, and failed to properly identify and implement Transmission Based Precautions for a resident with a VRE infection. Some staff were unaware of the correct precautions or the resident's status, and signage and documentation did not accurately reflect the required infection control measures.
A deficiency in infection control was observed during a meal service when a cook handled food without gloves and served it after sneezing without washing hands. The facility's hand hygiene policy was not followed.
The facility failed to use a gait belt during a transfer for a resident with a history of falls and severely impaired cognition, despite the resident's care plan and facility policy requiring it. Staff assisted the resident without a gait belt, leading to repeated falls and injuries.
The facility failed to maintain accurate advance directive records for two residents. One resident's chart lacked the Iowa Physician's Orders for Scope of Treatment (IPOST), while another resident's IPOST was missing a physician's signature, despite having a DNR order in the electronic health record. The DON confirmed these deficiencies during interviews.
Failure to Verify Morphine Concentration Leads to Repeated Overdose
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to Morphine administration. The resident was cognitively intact with a BIMS score of 12 and had diagnoses including Diabetes Mellitus, Anxiety Disorder, and COPD. The MDS and care plan identified the resident as dependent on staff for many ADLs and at risk for discomfort related to the end-of-life process, with directions to administer pain medications as ordered if non-medication interventions were ineffective and to evaluate the effectiveness of pain-relieving medications. A physician order specified Morphine Sulfate oral solution 10 mg/5 ml, with instructions to give 1 ml by mouth every 4 hours as needed for air hunger, which equated to a 2 mg dose per administration. Despite this order, the Morphine dispensed and received from the pharmacy was of a different concentration and labeling than ordered. The label on the plastic bag indicated a 100 ml bottle of Morphine Sulfate with directions to give 1 ml (2 mg) every 4 hours as needed, while the box label documented 30 ml Morphine Sulfate solution 100 mg per 5 ml (20 mg/ml) with directions to take 1 ml (20 mg total) every 4 hours as needed for severe pain or air hunger. The Controlled Medication Utilization Record also reflected Morphine 20 mg/ml with instructions to take 1 ml (20 mg) every 4 hours as needed. The EMAR, however, showed an order for Morphine Sulfate 10 mg/5 ml, give 1 ml every 4 hours as needed for pain or air hunger, and doses were signed out as given on three occasions. This discrepancy between the ordered concentration (10 mg/5 ml) and the dispensed concentration (20 mg/ml) was not identified or reconciled by nursing staff prior to administration. Nursing staff actions and inactions contributed directly to the medication error. One LPN reported that when she administered Morphine, she looked at the EMAR but did not look at the dosage on the EMAR or check the concentration; she focused only on the instruction to give 1 ml and relied on the bottle label and narcotic sheet, both of which indicated 1 ml equaled 20 mg. She acknowledged that she did not verify the dose against the original order and that the EMAR did not specify the milligram amount, only the volume. An RN who later administered two additional doses stated she checked the narcotic sheet and PCC, saw Morphine 20 mg/ml with instructions to give 1 ml every 4 hours as needed, and administered 20 mg doses without reviewing the original order or questioning the size of the dose. Another RN acknowledged that the process used when the Morphine was delivered did not follow the usual practice of two nurses comparing the bottle and paperwork against the order. The DON confirmed that the original order was for Morphine 10 mg per 5 ml, give 1 ml (2 mg), and stated that the nurses failed to double check the dose against the order even though it was correctly transcribed on the MAR. The pharmacist later confirmed that the pharmacy had received an order for Morphine 10 mg per 5 ml but dispensed Morphine 100 mg per 5 ml (20 mg/ml) due to an initial data entry error, and the ARNP verified that the order she wrote was for 10 mg per 5 ml, 1 ml (2 mg) every 4 hours PRN, with a maximum of 12 mg per day. The sequence of events shows that the resident received three doses of Morphine at 20 mg per dose instead of the ordered 2 mg per dose. Progress notes documented that the resident had labored breathing and air hunger, with Morphine given to assist with breathing and pain, and that the resident remained lethargic with decreased urine output and minimal intake. A subsequent note indicated that the Morphine was discontinued while awaiting a new order, and later that day the resident was found without pulse or respirations. Interviews with staff and the ARNP and primary care physician confirmed that the wrong concentration and dose of Morphine had been dispensed and administered, and that the resident had been in a declining state with end-stage COPD and hospice care. The facility’s policies required nurses to compare received medications with the MAR and clarify discrepancies before administration, and to review the five rights during medication administration, but these steps were not effectively carried out in this case, resulting in the significant medication error. Additional documentation from the facility’s incident report and staff interviews further detailed the breakdown in verification processes. Staff described that the pharmacy label and narcotic record both reflected the higher concentration and dose, and that one nurse sought informal reassurance from hospital nurses using discharge paperwork rather than verifying against the original written order or contacting the prescriber or pharmacy for clarification. Another nurse acknowledged that she did not question whether 20 mg was an appropriate dose for the resident and did not know what a normal dose would be for a hospice resident. The night shift supervisor stated he advised use of Morphine for air hunger based on the resident’s labored respirations but was unaware at the time that the wrong dose was being administered. The ARNP later discovered the discrepancy when another LPN questioned the medication, and the pharmacist confirmed that the pharmacy had dispensed the wrong concentration based on an incorrect drug selection during order entry. These combined actions and omissions by the pharmacy and nursing staff led to the administration of Morphine at ten times the ordered dose on three occasions, constituting the significant medication error identified by surveyors.
Failure to Inform Residents of Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to inform residents or their representatives in advance about the risks and benefits of psychotropic medications for five residents who were prescribed such medications. Clinical record reviews, policy review, and staff interviews revealed that, despite facility policy requiring notification and consent for the initiation, increase, or decrease of psychoactive medications, there was no documentation that this information was provided to the residents or their representatives. The affected residents had various diagnoses, including dementia, anxiety, depression, diabetes, osteoarthritis, asthma, chronic obstructive pulmonary disease, hemiplegia, and insomnia, and were prescribed medications such as sertraline, trazodone, olanzapine, alprazolam, duloxetine, buspirone, and Tylenol PM. The review of medical records and order summaries for these residents showed that psychotropic medications were administered without documented evidence that the residents or their responsible parties were informed of the associated risks and benefits prior to administration. Interviews with facility staff, including the DON, confirmed the absence of consent forms for these medications, and there was an acknowledgment that the pharmacist would assist in completing them. This lack of documentation and communication represents a failure to comply with facility policy and regulatory requirements regarding informed consent for psychotropic medication use.
Expired Nutritional Supplements Found in Kitchen Storage
Penalty
Summary
During an initial kitchen tour, surveyors observed 13 individual cartons of Glucerna creamy strawberry nutritional supplement with an expiration date of July 2025 stored on a dry storage shelf alongside other supplement drinks. The Dietary Manager confirmed that these Glucerna drinks were expired and acknowledged their presence in the storage area. Staff interviews revealed that the Dietary Aide responsible for checking supplements daily had overlooked the expired product because no residents were currently prescribed that particular flavor. Facility policy required kitchen staff to discard any food item in storage after its expiration date, but this was not followed in this instance.
Failure to Notify Ombudsman of Resident Hospitalizations and Discharges
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of the hospitalization and discharge of two residents. For one resident with chronic obstructive pulmonary disease and diabetes, who was cognitively intact, the clinical record showed a hospitalization and subsequent return to the facility, but there was no documentation of Ombudsman notification. The Minimum Data Set (MDS) and progress notes confirmed the resident's transfer to the hospital and return, yet the required notification was not present in the records. The facility administrator confirmed that staff did not notify the Ombudsman and that there was no policy in place for such notifications. For another resident, the records indicated an admission and later discharge to home with hospice services, with the intent for end-of-life care at home. Again, the clinical record lacked documentation of notification to the State Long-Term Care Ombudsman regarding the discharge. The administrator and DON both stated they were unaware of the requirement to notify the Ombudsman in cases of resident discharges and hospitalizations.
Failure to Complete Required MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete required Minimum Data Set (MDS) assessments for two residents. For one resident, the quarterly MDS assessment due in July remained incomplete and was still listed as 'in progress' in the electronic health record as of late August. The MDS Coordinator acknowledged that MDS assessments had not been completed in a timely manner, citing insufficient time to complete the required work. The Director of Nursing confirmed that MDS assessments should be completed within the appropriate time frames. Another resident, who had diagnoses of chronic obstructive pulmonary disease and diabetes and was cognitively intact, experienced a hospitalization in July. The clinical record review showed that the required MDS discharge assessment with anticipated return and the reentry MDS assessment were not completed following the resident's transfer to and return from the hospital. Progress notes documented the resident's transfer to the hospital, admission, and subsequent return to the facility, but the necessary MDS assessments were missing. The Director of Nursing confirmed that these assessments should have been completed.
Failure to Address Medication and Skin Breakdown Risks in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with diagnoses including anxiety, osteoarthritis, asthma, and chronic lung disease, the care plan did not include information about the resident's use of diuretic and antidepressant medications, despite documentation in the Medication Administration Record and the facility's policy requiring care plans to address medications and their potential side effects. This omission left staff without guidance on monitoring for possible medication-related side effects. For another resident with hemiplegia, Parkinson's disease, and muscle wasting, the care plan addressed the risk of impaired skin integrity related to a suprapubic catheter but did not address the risk of skin breakdown on the coccyx. Clinical documentation indicated the presence of an open area on the coccyx, but this was not reflected in the care plan. The Director of Nursing confirmed that care plans should address high-risk medications and all risks for skin impairment.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Provide Consistent Resident Activities Due to Staffing Issues
Penalty
Summary
The facility failed to provide sufficient activities to meet the needs of all residents, as evidenced by the lack of consistent activity programming for three residents with varying medical and psychological diagnoses. Documentation and interviews revealed that scheduled activities were frequently canceled or not held, particularly when the Activity Director, who also worked as a CNA, was assigned to resident care duties. Residents reported that many activities listed on the calendar did not occur, and there were no activities on weekends. Staff interviews confirmed that the Activity Director was unable to complete approximately 40% of scheduled activities due to being pulled to work the floor, and weekend staff did not consistently provide activities as expected. Clinical record reviews showed that residents valued and wished to participate in activities such as reading, group events, religious practices, and outdoor time, but participation records indicated sporadic attendance, with some residents only participating in activities on a handful of days over several months. Observations further confirmed that scheduled group activities were not held as planned, and documentation lacked evidence of activities being offered on many days. The facility's own policy required an ongoing person-centered activity program, but this was not consistently implemented due to staffing issues and competing responsibilities for the Activity Director.
Failure to Offer Pneumococcal Vaccine per CDC Guidelines
Penalty
Summary
The facility failed to offer a pneumococcal conjugate vaccine to one of five sampled residents reviewed for immunizations. According to the clinical record, the resident had previously received a dose of Pneumovax (PPSV23) in 2010 and was over the age threshold at the time. The resident's record did not contain documentation that staff had offered or administered a pneumococcal conjugate vaccine (such as Prevnar 20, Prevnar 21, or Vaxneuvance) in accordance with current CDC guidelines. The Infection Preventionist confirmed that the resident should have been offered the vaccine based on their immunization history. Facility policy required nursing staff to screen residents for pneumonia vaccination status upon admission, provide education on the risks and benefits of the pneumococcal vaccine, and document both the education and the resident's consent or declination. However, the review found that this process was not followed for the resident in question, as there was no evidence of an offer, education, or documentation regarding the pneumococcal conjugate vaccine. The deficiency was identified through clinical record review, policy review, CDC guideline comparison, and staff interviews.
Failure to Maintain Resident Dignity and Proper Use of Incontinent Products
Penalty
Summary
Staff failed to ensure a resident was dressed in a dignified manner and that incontinent products were used appropriately. The resident, who had diagnoses including non-Alzheimer's dementia, anxiety disorder, and diabetes, was dependent on staff for lower body dressing and toileting hygiene, with a BIMS score indicating moderately impaired cognition. Observations and staff interviews revealed that the resident was brought to the dining room after a shower wearing only a nightgown and a lap blanket covering her legs, and on another occasion, with only a shirt, a brief, and a blanket. Staff acknowledged this was a dignity issue and that the resident should have been dressed in pants before being brought to the dining area. Additionally, staff were observed and reported to have applied more than one incontinent product to the resident, such as a pull-up with a pad inside, which was not in accordance with appropriate care practices. Staff indicated this was done because the resident was a heavy wetter, but acknowledged that the correct approach would be to change the resident more frequently rather than using double products. The Director of Nursing was not aware of these incidents at the time of the interviews.
Failure to Assist Resident with Activities of Daily Living
Penalty
Summary
A deficiency was identified regarding the provision of care and assistance with activities of daily living (ADLs) for residents who are unable to perform these tasks independently. The report notes that care and assistance were not provided as required for at least one resident who was unable to complete ADLs without help. This failure to provide necessary support directly affected the resident's ability to perform daily self-care activities.
Failure to Assess Skin Impairments and Coordinate Hospice Care
Penalty
Summary
The facility failed to adequately assess and document areas of skin impairment for a resident with multiple diagnoses, including non-Alzheimer's dementia, anxiety disorder, and diabetes. The resident was identified as being at risk for pressure ulcers and had moderately impaired cognition. There was no documentation of assessment or application of bandages for a toe abrasion and a forearm skin tear prior to the dates when these were discovered and recorded. Staff interviews revealed that a CNA had applied bandages, which was against facility policy, and the DON confirmed that CNAs were not permitted to perform this task. Additionally, the facility did not document care planning, collaboration, or communication with hospice services for a resident receiving end-of-life care. The care plan for this resident did not reflect hospice involvement or interventions, despite the resident being on hospice services. There was no evidence that hospice staff were invited to care plan meetings, and the hospice RN confirmed not being invited or notified of changes in the resident's condition or medication orders. The facility's clinical record lacked documentation of communication with hospice regarding significant changes and medication adjustments. There was also a discrepancy between the facility's electronic health record and hospice documentation regarding oxygen orders for the resident on hospice. The facility continued to document and administer oxygen at 2 liters per nasal cannula, while hospice orders specified 5 liters continuous. The facility did not update the EHR to reflect the hospice order, and the DON was unaware of this discrepancy. The facility's contract with hospice required immediate notification of significant changes and coordination of care, which was not documented in these instances.
Failure to Implement and Identify Correct Infection Control Precautions
Penalty
Summary
Staff failed to consistently wear appropriate personal protective equipment (PPE) during high-contact care activities for residents on Enhanced Barrier Precautions (EBP) and did not correctly implement or identify the required level of infection control precautions for a resident on Transmission Based Precautions (TBP). For one resident with arthritis, heart failure, hypertension, and unstageable pressure ulcer, staff measured and cared for wounds while wearing gloves but not a gown, despite facility policy requiring both gown and gloves for wound care under EBP. Staff interviews confirmed knowledge of the policy, but the LPN involved did not wear a gown, stating she did not expect drainage from the wound. Another resident with chronic obstructive pulmonary disease, fibromyalgia, and an indwelling urinary catheter required substantial assistance with personal hygiene and had excoriated areas identified as a yeast infection. During personal care and catheter-related activities, one LPN wore only gloves while assisting with intimate care tasks, including repositioning and perineal care, while another LPN wore both gown and gloves. The LPN who did not wear a gown stated she believed it was unnecessary since she was not performing catheter care, despite direct contact with the resident and the presence of open skin areas. For a third resident with chronic obstructive pulmonary disease, diabetes, and an indwelling urinary catheter, the facility failed to clearly identify and implement the correct level of infection control precautions. Although the resident was on TBP for a Vancomycin Resistant Enterococci (VRE) infection, the signage on the door only indicated EBP, and the resident was not listed on the facility's matrix as being on TBP. Staff interviews revealed confusion between EBP and TBP, and some staff were unaware of any residents on contact precautions, despite the resident's status and facility policy requiring contact precautions for VRE.
Infection Control Breach During Meal Service
Penalty
Summary
During an observation of the noon meal service, a deficiency was identified in the facility's infection control measures. The cook, identified as Staff D, failed to wear gloves while handling buns, which were then served to residents. Additionally, Staff D sneezed on her right arm while holding a plate of food in her left hand and proceeded to serve the plate to a resident without washing her hands. The facility's hand hygiene policy, revised in January 2017, mandates that hands should be washed before handling food and after sneezing, coughing, or blowing the nose. This policy was not adhered to during the observed meal service.
Failure to Use Gait Belt During Transfer
Penalty
Summary
The facility failed to utilize a gait belt during a transfer for a resident with a history of falls, anxiety disorder, and diabetes, who required substantial assistance for toilet transfers and had severely impaired cognition. On multiple occasions, the resident was found on the floor after yelling for help, resulting in injuries such as a laceration on the forehead that required stitches and a goose egg on the head. Despite the resident's care plan indicating a risk for falls and the facility's policy requiring the use of gait belts for transfers, staff did not use a gait belt during a transfer observed on 5/14/24, even though one was available in the room. Instead, staff held the resident under her arms to assist her in standing and walking a few steps to her wheelchair after using the commode. This failure to follow protocol was confirmed by the Director of Nursing, who stated that staff should have used a gait belt with the resident. The resident's care plan entries highlighted her impaired mobility, fluctuating ability to transfer, and poor weight-bearing capacity, which increased her risk of falls. The facility's policy on falls prevention, revised in 4/2024, mandated the use of gait belts for patient transfers based on risk assessments. However, during the observed transfer, staff did not adhere to this policy, leading to a deficiency in ensuring a safe transfer process for the resident. This oversight contributed to the resident's repeated falls and injuries, demonstrating a lapse in the facility's adherence to its own safety protocols.
Deficiency in Advance Directive Documentation
Penalty
Summary
The facility failed to maintain accurate advance directive records for two residents, leading to deficiencies in their care documentation. Resident #8, who was cognitively intact with diagnoses including Coronary Artery Disease and Cerebrovascular Accident, did not have the Iowa Physician's Orders for Scope of Treatment (IPOST) in their chart. This was confirmed during a record review and an interview with the Director of Nursing (DON), who was unable to locate the IPOST initially. Resident #9, who had moderate cognitive impairment and was admitted to Hospice Care, had an IPOST indicating a Do Not Attempt Resuscitation (DNR) choice, but it lacked the necessary physician's signature. The electronic health record showed an active DNR order, but the physical IPOST document was incomplete. The DON confirmed the absence of the physician's signature during an interview, acknowledging the need for the signature to validate the IPOST.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
