Monticello Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Monticello, Iowa.
- Location
- 500 Pinehaven Drive, Monticello, Iowa 52310
- CMS Provider Number
- 165279
- Inspections on file
- 24
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Monticello Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with severe dementia, behavioral symptoms, and total dependence on staff for care was being assisted in bed by two CNAs when the resident jabbed one CNA in the eye. According to an eyewitness CNA and multiple staff interviews, the CNA who was struck became angry, grabbed the resident by the shoulders, shook him, and loudly cursed at him, telling him to "shut the f**k up" and making additional threatening statements, while the roommate overheard profanity directed at the resident. The charge RN was informed that the CNA had yelled at and grabbed the resident, and an assessment showed no physical injury, but the facility’s investigation concluded that the CNA had verbally abused the resident and that physical abuse in the form of aggressively grabbing the resident’s shoulders had been reported, in violation of the facility’s abuse-prevention policy.
A resident with Alzheimer’s disease, traumatic brain injury, seizure disorder, and a documented history of multiple falls and behavioral issues was care planned as a fall risk requiring frequent checks and environmental precautions. Despite this, staff allowed the resident to keep the door closed and relied on the resident’s call light or yelling for needs, and hallway camera footage showed no staff entered the room for the entire night shift after a CNA administered bedtime meds. The next morning, a CNA found the resident in bed with a swollen, bloody lip and abrasions on the arm and shin, with blood on the nightstand, tray table, and floor, and the resident gave inconsistent accounts alleging staff assault. Review of camera footage and staffing records showed no staff entry into the room overnight, and staff concluded the injuries most likely resulted from an unwitnessed fall that occurred while the resident was not visually checked, demonstrating a failure to provide adequate supervision and monitoring to prevent accidents.
Multiple incidents occurred where a resident with severe cognitive impairment physically struck another resident, and another resident with moderate cognitive impairment engaged in inappropriate sexual contact with two female residents. Despite care plans and policies addressing behavioral symptoms and cognitive impairment, supervision and interventions were insufficient to prevent these altercations and inappropriate behaviors.
A resident with severe cognitive impairment and a history of physical behavioral symptoms was involved in multiple physical altercations with another resident, including slapping, after entering the other's room. Staff relied on redirection and periodic checks, but did not provide one-on-one supervision or maintain consistent interventions, resulting in a failure to prevent the altercation.
A facility failed to maintain a resident's dignity by not using a dignity bag for an indwelling urinary catheter, despite multiple observations of the catheter bag being visible. The resident, with severe cognitive impairment, required catheter care as per their care plan. Staff interviews revealed that both CNAs and nurses are responsible for ensuring dignity bags are used, but a CNA admitted to forgetting due to nervousness. The DON confirmed the availability of dignity bags and staff training on their importance.
The facility failed to notify residents of their right to appeal Medicare Part A discharge decisions, despite having remaining benefit days. Documentation lacked evidence of notification, and necessary forms were not completed, affecting three residents who continued to reside in the facility.
A resident with intact cognition was not accounted for when leaving the facility to smoke, as required by their Care Plan. The resident exited and re-entered the facility without signing out or in, and staff were unaware of the requirement. The facility's Smoking Policy did not specify responsibility for tracking resident location during smoking.
A facility failed to maintain consistent Hemodialysis communication records for a resident with chronic kidney disease over two months. The resident's care plan required dialysis thrice weekly, but forms were missing from her clinical record. Staff were unclear about the location of these forms, with only one form found for the period, contrary to policy requirements.
The facility failed to conduct required Smoking Assessments for two residents, one with moderate cognitive impairment and another with intact cognition, both identified as current smokers. The assessments were not completed upon admission or quarterly, as required, leading to a deficiency in ensuring a safe environment. The DON acknowledged the oversight and the facility's Smoking Policy lacked guidance on assessing residents' smoking capabilities.
Verbal and Physical Mistreatment of a Cognitively Impaired Resident by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal mistreatment by staff. The resident involved had severe cognitive impairment due to Alzheimer’s disease, cancer, and a history of physical and verbal behaviors directed toward others. According to the MDS, the resident required staff assistance for transfers, used a wheelchair, and had sustained a prior fall with injury. The care plan directed staff to redirect behaviors, step away and re-approach if the resident was resistive, and to verbally reward positive behavior. On the day of the incident, two CNAs were in the resident’s room providing care before lunch. The resident became combative and jabbed one CNA in the eye while being rolled for incontinence care. Multiple staff accounts, including those of the ADON, DON, charge RN, and the eyewitness CNA, consistently described that after being struck in the eye, the CNA who was hit became upset. The eyewitness CNA reported that the CNA who was struck backed away briefly, then grabbed the resident by the shoulders, shook him, and told him to “shut the f**k up,” repeating this loudly twice. She also reported that he said words to the effect of, “If you weren’t a resident, I would beat the s**t out of you.” The Administrator’s account of the eyewitness report included that the CNA also said, “If you weren’t a resident I would f**ing kill you.” The roommate, who had moderate cognitive impairment, reported hearing the staff member call the resident a “f**er” after the resident poked the staff in the eye, and stated that the staff did not hit or hurt the resident. The charge RN documented that she was notified by a CNA that another CNA yelled at the resident, grabbed him by the shoulders, and made threatening statements. When the RN entered the room shortly after, the resident was smiling, denied pain or discomfort, and a full body assessment revealed no visible injury. The facility’s investigation concluded that verbal abuse was verified based on the eyewitness CNA’s account and corroboration from the roommate, and that physical abuse in the form of aggressively grabbing the resident’s shoulders was reported by the eyewitness CNA, though denied by the accused CNA. The facility’s abuse policy in effect stated that all residents have the right to be free from abuse, including verbal and physical abuse, and that residents must not be subjected to abuse by anyone.
Failure to Adequately Supervise High-Risk Resident Leading to Unwitnessed Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and monitoring for a resident with a known history of falls and behavioral issues. The resident had diagnoses including Alzheimer’s disease, hypertension, traumatic brain injury, and seizure disorder, and the MDS documented two or more prior falls with non‑major injury. The care plan identified the resident as a fall risk related to poor safety awareness and impaired balance, and also noted physical behaviors, behaviors directed toward others, and a risk for making false accusations. The care plan interventions included ensuring the call light was within reach, use of appropriate footwear, leaving the bathroom door ajar with the light on, and encouraging the resident to keep the door open at night to allow for more frequent staff checks. Despite these identified risks and interventions, the resident was allowed to keep his door closed with a sign instructing staff to knock before entering, and staff relied primarily on the resident’s use of the call light or yelling from the doorway rather than consistent in‑person checks. On the night of the incident, camera footage showed that a CNA entered the resident’s room at approximately 9:36 p.m. to administer bedtime medication, after which no staff entered the room again until about 6:15 a.m. the following morning. During that interval, the resident did not activate his call light. Staff interviews confirmed that the nurse on duty did not go into the resident’s room during the shift and believed that an aide had done so, while the agency aide assigned to the hall did not actually enter the room, instead only going to the door and listening because the resident became angry when staff opened his door. This pattern of inaction resulted in a prolonged period—roughly the entire night shift—during which no staff member visually assessed the resident, despite his documented fall history, behavioral issues, and care plan direction for more frequent checks. At approximately 6:10–6:15 a.m., a CNA entered the resident’s room for morning care and found him in bed with smeared blood on his chin and a swollen, reddened lower lip with an internal laceration, as well as abrasions on his right arm and right shin. Blood was observed on the nightstand, on the leg of the tray table, and on the floor next to it. The resident reported that an employee had come into his room and assaulted him, at various times describing the assailant as a female employee, a male employee, and later accusing a maintenance worker of beating him and taking his closet door. Review of hallway camera footage and staffing records showed no staff entry into the room during the night and no male CNAs on duty, contradicting the resident’s accounts. Based on the location of the blood and the absence of staff entry, facility staff concluded that the injuries most likely resulted from an unwitnessed fall that occurred while the resident was unsupervised for an extended period, demonstrating that the facility did not ensure adequate supervision and monitoring to prevent accidents for this high‑risk resident. The resident’s prior incident history further underscored his need for closer supervision. Earlier incident reports documented a fall in the hallway after he threw his cane and lost his balance, and another unwitnessed event where staff heard a loud bang and found him seated on the floor near his bathroom door, with the resident unable to explain how it happened. Observations during the survey showed that he typically stayed in his room with the door shut, ate meals there, and often refused to sit in a recliner for meals, preferring the edge of the bed. Staff described him as using his call light or yelling from his doorway when he wanted something, and as being noncompliant with attempts to make him an assist‑of‑one for mobility or to use a gait belt. Despite these known behaviors and risks, staff on the night of the incident did not perform in‑person checks or “lay eyes” on him for many hours, which directly led to his injuries from an unwitnessed event that went unrecognized until the morning. The facility’s own investigation and staff interviews acknowledged that the lack of rounding and failure to visually check the resident during the night were unacceptable and contrary to expectations that residents be checked at least every two hours or hourly. Staff reported that they had been relying on the resident’s call light use and his tendency to yell for assistance, and that the agency aide did not enter the room because the resident disliked having his door opened. The combination of the resident’s closed door, his behavioral and cognitive issues, his fall history, and staff’s failure to conduct required rounds and direct observation resulted in the resident sustaining injuries from an unwitnessed fall or accident that occurred without timely detection or intervention, constituting the cited deficiency in accident prevention and adequate supervision.
Failure to Prevent Resident-to-Resident Altercations and Inappropriate Behaviors
Penalty
Summary
The facility failed to provide adequate supervision to prevent resident-to-resident altercations and inappropriate behaviors, as evidenced by multiple incidents involving residents with cognitive impairments and behavioral symptoms. One resident with severe cognitive impairment and a history of physical behavioral symptoms was observed striking another resident in the hallway after a verbal altercation. The care plan for this resident included interventions such as moving the resident to a calm environment and maintaining distance from others, as well as 15-minute checks, but the incident still occurred, indicating a lapse in supervision and implementation of interventions. Another resident with moderate cognitive impairment was involved in two separate incidents of inappropriate sexual contact with female residents. In one case, the resident was observed groping a female resident's breast while watching television, and in another, the same resident was seen rubbing another female resident's thigh in the dining room, despite her attempts to push his hand away. The care plan for this resident directed staff to prevent sexual contact with a specific resident but did not include interventions to prevent similar behavior with other residents. Staff and resident interviews confirmed that these incidents were witnessed and reported by both staff and other residents. The facility's policies on managing inappropriate resident behavior and sexual relationships for cognitively impaired residents were reviewed. The policy on resident-to-resident aggression directed immediate intervention and separation but did not specify further preventive measures. The policy on sexual relationships defined cognitive impairment and outlined the need to protect residents unable to provide consent, but the care plans and supervision in practice were insufficient to prevent repeated incidents. These deficiencies demonstrate a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents and inappropriate behaviors.
Failure to Prevent Resident-to-Resident Altercation Involving Cognitively Impaired Resident
Penalty
Summary
The facility failed to prevent a resident-to-resident altercation involving two residents, one of whom had severe cognitive impairment and a history of physical behavioral symptoms such as hitting, kicking, and pushing. The resident with cognitive impairment had diagnoses including non-Alzheimer's dementia, anxiety, and post-traumatic stress disorder, and was noted to be confused, agitated, and prone to entering other residents' rooms. Despite these known behaviors, the resident was not provided with one-on-one supervision and staff primarily relied on redirection and periodic checks. Multiple incidents were documented in which the cognitively impaired resident physically interacted with others, including elbowing, shoving, and ultimately slapping another resident. The most recent incident involved the resident entering another resident's room, becoming agitated, and slapping the other resident, who then retaliated. Staff responded by separating the residents, but no injuries were observed. Interviews with staff indicated that the resident required frequent redirection and was difficult to monitor continuously, as she would not remain in one place and did not participate in activities. The care plan for the resident with behavioral symptoms included interventions such as 15-minute checks and keeping distance between her and others when she became physically abusive. However, these interventions were not consistently maintained, and the resident was not provided with enhanced supervision despite a pattern of escalating behaviors. The facility's abuse prevention policy required identification and intervention for high-risk situations, but the measures in place were insufficient to prevent the altercation.
Failure to Maintain Resident Dignity with Catheter Care
Penalty
Summary
The facility failed to protect a resident's dignity by not ensuring that the indwelling urinary drainage bag was kept in a dignity bag for a resident with an indwelling catheter. The resident, identified as severely cognitively impaired with a BIMS score of 4 out of 15, had diagnoses including cerebral infarction and compression of the brain. Observations on multiple occasions revealed the Foley catheter bag hanging off the bed frame without a dignity bag, visible to anyone entering the room. These observations occurred over two consecutive days, despite the resident's care plan indicating the need for appropriate catheter management. Interviews with facility staff, including a CNA and an LPN, confirmed that both nurses and nurse aides are responsible for ensuring the catheter bag is placed in a dignity bag to respect the resident's privacy. The CNA admitted to forgetting to place the dignity bag during catheter care due to nervousness. The DON acknowledged that dignity bags should be used whenever the catheter bag is visible to others or when the resident has visitors. The facility had dignity bags available and provided training to staff on their importance, yet the deficiency persisted.
Failure to Notify Residents of Medicare Discharge Rights
Penalty
Summary
The facility failed to provide proper notification to residents and/or their representatives regarding the right to appeal decisions for discharge from Medicare Part A, despite having remaining benefit days. This deficiency was identified for three residents who were discharged from Medicare Part A services but continued to reside in the facility. The facility's documentation, including the Beneficiary Notice and Electronic Health Records, lacked evidence of notification prior to discharge for these residents. Additionally, the facility did not complete the necessary forms, such as Form CMS-10055 and the Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, which are required to inform residents of their rights and the coverage status. The facility's failure to provide these notifications was confirmed through staff interviews and a review of the relevant documents. The facility was unable to produce completed NOMNC forms for the residents in question, indicating a systemic issue in the notification process. The facility's administrator acknowledged the inability to locate the required forms, further highlighting the deficiency in ensuring residents were informed of their Medicare coverage status and their right to appeal discharge decisions.
Failure to Account for Resident Location During Smoking
Penalty
Summary
The facility failed to account for the location of a resident who chose to smoke, as outlined in the resident's Care Plan. Resident #29, who has intact cognition with a BIMS score of 14 out of 15, was documented to use tobacco and was required to sign out on a Leave of Absence form when leaving the facility to smoke. However, the form was incomplete, with the resident's name and facility left blank, and there was no documented time for signing back in. Observations revealed that Resident #29 exited and re-entered the facility without signing out or in, despite the Care Plan's intervention requirement. Interviews with staff, including an LPN and the DON, confirmed that the designated smoking area was off the premises and that Resident #29 left the building multiple times a day to smoke without signing out. The DON and Administrator acknowledged that Resident #29 had only signed out once in the past month, indicating a failure to adhere to the Care Plan. The facility's Smoking Policy, revised in 2022, did not specify the responsibility for accounting for resident location when smoking, contributing to the deficiency.
Inconsistent Hemodialysis Record-Keeping
Penalty
Summary
The facility failed to maintain consistent records of Hemodialysis communication for a resident with chronic kidney disease and congestive heart failure over a two-month period. The resident, who had intact cognition, required dialysis three times a week as per her care plan. However, her clinical record did not include Hemodialysis communication forms for September and October 2024. Staff interviews revealed confusion about the location of these forms, with one nurse unaware of the existence of a Dialysis book and the Director of Nursing expecting the forms to be in the dialysis book. Only one form was found for the past two months, contrary to the facility's policy that required documentation of vital signs and communication with the dialysis facility before and after dialysis sessions.
Failure to Conduct Smoking Assessments for Residents
Penalty
Summary
The facility failed to complete the required Smoking Assessments for two residents, leading to a deficiency in ensuring a safe environment free from accident hazards. Resident #1, with moderate cognitive impairment and multiple health conditions, was identified as a current smoker upon admission. However, the facility did not conduct any Smoking Assessments to evaluate Resident #1's capabilities and deficits to safely smoke, neither upon admission nor quarterly as required. This oversight was confirmed by both the resident and the staff responsible for the initial assessment. Similarly, Resident #29, who had intact cognition and was also a current smoker, did not receive the necessary quarterly Smoking Assessments. Although some assessments were completed, there were significant gaps, with missed assessments on several occasions. The Director of Nursing acknowledged these lapses and confirmed that the facility's Smoking Policy did not adequately address the need for assessing residents' capabilities and deficits to safely smoke.
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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