North Crest Living Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Council Bluffs, Iowa.
- Location
- 34 Northcrest Drive, Council Bluffs, Iowa 51503
- CMS Provider Number
- 165290
- Inspections on file
- 19
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 24
Citation history
Health deficiencies cited at North Crest Living Center during CMS and state inspections, most recent first.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident with moderate cognitive impairment and an indwelling catheter had multiple shifts with low or no urinary output, but there was no documentation that as-needed catheter flushes were performed as ordered. Staff interviews confirmed that a flush should have been done when output was 100mL or less, and the resident was later hospitalized for sepsis secondary to a urinary tract infection.
Staff did not follow Enhanced Barrier Precautions when providing catheter and peri care to a resident with an indwelling catheter. Two CNAs failed to perform hand hygiene before care and did not wear gowns as required, despite facility policy and EBP protocols. Staff interviews revealed confusion about when gowns were necessary, and observed practices did not align with infection control policies.
The facility had repeat deficiencies in areas including care planning and catheter care, with incomplete corrective actions despite a Performance Improvement Plan. Staff interviews confirmed that residents with catheters lacked care plans with appropriate focus, goals, or interventions, and at least one resident did not have a physician's order for catheter use prior to survey. The Administrator and DON acknowledged these deficiencies and delays in implementing required orders and care plans.
Laundry staff failed to use proper PPE while sorting soiled laundry, including not wearing gloves and incorrectly donning a gown. The DON, who took over as IP, found lapses in Enhanced Barrier Precautions implementation, such as missing or incorrect signage and incomplete infection surveillance mapping, following the termination of the previous IP for not completing required tasks.
Several residents with catheters, depression, or anxiety did not have individualized care plans with specific goals or interventions addressing their conditions. Care plans lacked resident-specific details for catheter management and behavioral health needs, and staff confirmed that documentation and interventions were not tailored to each resident as required by facility policy.
Several residents reported receiving cold meals in their rooms multiple times per week, with food temperatures observed by staff to be below required standards. Staff acknowledged the issue, and facility policy as well as FDA guidelines were not met, resulting in residents receiving unappetizing and improperly held food.
The facility did not follow required antibiotic stewardship practices, as the DON, acting as Infection Preventionist, used an incomplete tracking spreadsheet and was unaware of the actual number of residents on antibiotics or the use of infection assessment tools. Six residents were on antibiotics, but this was not recognized or monitored according to facility policy.
Three residents were not given the required CMS-10055 form or informed of their options and costs when Medicare Part A coverage ended. Each resident, with varying cognitive abilities and medical needs, transitioned to private pay without receiving proper notification or explanation of their rights and financial responsibilities. The responsible social worker was unfamiliar with the form and facility policy was not followed.
Multiple residents experienced unclean rooms and unmade beds due to a shortage of clean linen and delays in housekeeping, with staff reporting communication issues and low linen supplies. Residents reported irritation and discomfort, and observations confirmed debris and personal items left in rooms throughout the day. Administration could not provide relevant housekeeping or linen policies when requested.
Three residents prescribed high-risk psychotropic medications did not have individualized care plans that identified non-pharmacological interventions or specific target behaviors related to medication use. Instead, care plans contained generic statements and lacked person-centered goals and interventions, despite staff and policy expectations for individualized documentation.
A resident with no cognitive impairment was transferred to the hospital for acute symptoms, but the facility did not provide the required bed hold notice or obtain verification from the resident or representative, as confirmed by EHR review and staff interviews. The DON and Administrator acknowledged the omission, which was not in accordance with facility policy or federal regulations.
Staff failed to obtain and follow physician orders for two residents: one resident's insulin was repeatedly held without doctor-specified parameters or notification, and another resident returned from the hospital with a urinary catheter but without a corresponding physician order. Nursing staff relied on their own judgment for insulin administration, and the facility did not ensure required orders for medical devices were in place, as confirmed by interviews with the DON and administrator.
A resident with multiple chronic conditions requiring continuous oxygen therapy was found to have undated oxygen tubing and no documented orders or instructions for tubing changes. Staff and administration confirmed the absence of a formal policy and inconsistent documentation, resulting in a failure to ensure safe and appropriate respiratory care in accordance with professional standards.
A resident diagnosed with dementia did not receive the necessary treatment and services appropriate for their condition, as required by regulatory standards.
Staff administered influenza vaccines to several residents without obtaining signed consent or providing required education about the vaccine's benefits and side effects. Medical records lacked documentation of consent and education, despite facility policy requiring these steps before vaccination. Leadership acknowledged the process was not consistently followed.
Staff failed to obtain signed consents and provide required education before administering the COVID-19 vaccine to three residents with various medical conditions, as evidenced by missing documentation in their records. The DON and Administrator confirmed that consents were not always properly documented, education was not consistently provided, and verbal consents lacked a second witness, contrary to facility policy.
The facility failed to provide adequate nursing staff, particularly on weekends, affecting resident care. A resident reported delays in call light responses, and staffing data showed lower PPD averages on weekends. Staff confirmed fewer aides were scheduled on weekends, and the facility's assessment acknowledged this discrepancy.
The facility failed to follow standard precautions and enhanced barrier precautions (EBP) in infection control practices. Laundry staff did not wear gloves and gowns while handling laundry, and a resident with an indwelling catheter reported staff not wearing gowns during care. The facility lacked a comprehensive infection prevention control policy, and staff were not adequately trained on EBP, particularly regarding the use of gowns. The infection preventionist and DON expected adherence to EBP, but the facility did not have an annually reviewed infection control policy.
A facility failed to obtain a physician order for a DNR status for a resident, despite the resident's IPOST indicating a DNR with limited interventions. The absence of a signed DNR order in the electronic medical records was confirmed by a social worker and acknowledged by the administrator. The facility's CPR Guideline required DNR orders to be obtained following state-specific guidelines, which was not followed in this case.
A facility failed to notify a resident 48 hours in advance when Medicare Part A coverage or Part B therapies were ending. The absence of an Advanced Beneficiary Notice (ABN) for the resident was noted, and the Administrator admitted the facility could not locate the form. It was also revealed that the facility lacks a specific policy for issuing ABNs, despite claiming adherence to federal regulations.
A facility failed to submit a comprehensive MDS assessment within the required timeframe for a resident, as per CMS guidelines. The assessments lacked transmission dates and acceptance, and a Discharge with Return Anticipated Assessment was missing. The MDS Coordinator, new to the position, was unsure about submission requirements, while the Administrator knew the impact on reimbursement but not the specific procedures.
The facility inaccurately documented medication use in the MDS for two residents, with one resident's MDS showing anticoagulant use without corresponding physician orders, and another's showing hypnotic and antianxiety medications without orders. Staff interviews confirmed these inaccuracies, and the facility lacked a specific policy for ensuring MDS accuracy.
The facility failed to include anticoagulant medication use in the care plans of two residents prescribed Eliquis, lacking interventions for monitoring bleeding and bruising. Staff interviews revealed a misunderstanding about care plan requirements, and the facility lacked a policy for ensuring accurate and personalized care plans.
A resident with heart failure and other conditions was transferred to the ED for chest pain and shortness of breath, but the facility failed to immediately notify the PCP as required. The DON acknowledged the notification was sent via fax without a recorded time, and the PCP confirmed not receiving a call about the transfer.
The facility failed to obtain bed hold notifications for two residents during their hospital transfers. A resident was sent to the emergency room for a forehead laceration after a fall, but no bed hold form was available. Another resident was hospitalized, but the facility did not have a signed bed hold form. The Administrator acknowledged the issue, especially for weekend hospitalizations, and admitted the lack of a specific policy for bed hold notifications.
A resident with heart failure and renal insufficiency did not have daily weights recorded as ordered by the physician. Despite orders for daily weights, the facility failed to document weights over a series of days. The DON was unable to explain the lapse in following the physician's orders.
The facility failed to implement fall prevention interventions for three residents, leading to falls and injuries. A resident with moderate cognitive impairment fell and fractured a femur after being left unattended. Another resident was improperly assisted without a gait belt, increasing fall risk. A third resident with severe cognitive impairment experienced multiple falls due to inadequate adherence to care plan interventions. The facility's protocols for fall prevention and call light response were not effectively followed.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses for two residents with moderate cognitive impairment. One resident experienced delays of 25-35 minutes, particularly during meals, while another resident reported delays leading to self-transfer to the bathroom. Facility records showed multiple instances of call light responses exceeding 15 minutes. Staff acknowledged the expectation to respond within 15 minutes, but this was not always met, especially during meals.
Facility staff failed to maintain infection control practices during personal care for a resident with severe cognitive impairment. Two CNAs were observed performing hygiene and transfer without proper hand hygiene between glove changes, contrary to the facility's handwashing protocol. The DON acknowledged the standard of care requires hand hygiene between glove changes.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Provide Appropriate Catheter Care and Prevent UTI
Penalty
Summary
The facility failed to provide appropriate interventions for a resident with an indwelling urinary catheter, as evidenced by a lack of response to decreased or absent urinary output over multiple shifts. The resident, who had moderate cognitive impairment and a physician's order for as-needed catheter flushes in the event of clogging or dysfunction, consistently had recorded outputs of 100mL or less per shift, including several instances of 0mL output. Despite these findings, there was no documentation in the Medication Administration Record, Treatment Administration Record, or progress notes indicating that the as-needed catheter flushes were performed during the period in question. Staff interviews confirmed that the expectation was to perform a catheter flush when output was 100mL or less per shift, and that such interventions should be documented. Nursing staff acknowledged that they would have performed a flush under these circumstances, and the Director of Nursing stated that nurses should be notified of decreased output and should investigate further. The resident was ultimately hospitalized for acute respiratory failure related to sepsis secondary to a urinary tract infection. Facility policy required preventive measures for infection control in residents with urinary catheters, including changing catheters per orders.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
Staff failed to follow appropriate infection prevention and control practices when providing care to a resident with an indwelling catheter who was on Enhanced Barrier Precautions (EBP). During an observed episode of catheter and peri care, two CNAs entered the resident's room, applied gloves, but did not perform hand hygiene prior to care or don gowns as required by EBP protocols. One CNA assisted the resident with standing using a gait belt, while the other performed catheter and peri care, including cleansing the catheter, penis, and buttocks, and then assisted with dressing. After care, one CNA removed gloves and performed hand hygiene, while the other removed gloves, gathered trash, exited the room, and only performed hand hygiene in the hallway outside the soiled utility room. Interviews with staff revealed a lack of understanding regarding the requirement to wear gowns during catheter and peri care under EBP, with some staff believing gowns were only necessary when emptying the catheter or not required during bowel movements. The facility's policies, as confirmed by the DON and LPN, required gowns and gloves for all catheter and peri care, as well as hand hygiene before and after resident contact and glove use. The observed practices did not align with these policies, resulting in a failure to implement proper infection prevention measures for a resident with an indwelling catheter.
Repeat Deficiencies and Incomplete Performance Improvement for Catheter Care and Care Planning
Penalty
Summary
The facility failed to demonstrate good faith attempts to correct previously identified quality deficiencies, as evidenced by repeat deficiencies in three areas and incomplete corrective actions outlined in a Performance Improvement Plan (PIP). Document review showed that deficiencies related to notice of bed hold policy, development and implementation of comprehensive care plans, and provision of services meeting professional standards were cited in a previous recertification survey, with correction dates that had passed. Additionally, a PIP addressing compliance with federal regulation F880 was not completed within the targeted timeframe, and action steps to ensure appropriate catheter orders and care plans were not fully implemented. Interviews with the Director of Nursing (DON) and the Administrator confirmed that residents using catheters did not have care plans with appropriate focus, goals, or interventions, and that at least one resident did not have a physician's order for catheter use prior to the survey. The Administrator acknowledged delays in entering necessary orders and care plans, and recognized that the facility lacked routine orders for catheters. The facility's Quality Assurance and Performance Improvement (QAPI) program documentation indicated a commitment to setting and measuring progress toward performance goals, but the identified deficiencies and incomplete corrective actions demonstrated a failure to achieve compliance.
Failure to Follow Infection Control Standards and Inconsistent Infection Preventionist Oversight
Penalty
Summary
The facility failed to adhere to infection control standards, as evidenced by laundry staff not wearing appropriate personal protective equipment (PPE) while handling soiled laundry. Specifically, an environmental aide was observed sorting dirty laundry without a gown or gloves. When the staff member attempted to don a gown, she initially put it on incorrectly and, after correcting it, still failed to apply disposable gloves before resuming her duties. This lapse in PPE use occurred during the handling of potentially contaminated linens, contrary to facility policy and infection control protocols. Additionally, the facility did not ensure consistent implementation of the responsibilities of the Infection Preventionist (IP). The DON reported assuming IP duties after discovering that the previous IP, the ADON, was not completing required tasks and was subsequently terminated. The DON identified issues such as residents who should have been on Enhanced Barrier Precautions (EBP) lacking appropriate signage and PPE, while others had unnecessary signage. Infection surveillance mapping was incomplete for recent months, and these failures were not in alignment with the facility's own infection prevention and control program policies.
Failure to Develop Comprehensive and Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for several residents, specifically those with indwelling catheters, depression, and anxiety. For multiple residents with catheters, including those with moderate cognitive impairment and recent hospitalizations for fractures, the care plans lacked any focus, goals, or interventions related to catheter use. Documentation and interviews confirmed that these omissions were present at the time of the survey, and the Director of Nursing acknowledged that care plans for catheter use had not been developed as expected. Additionally, residents with diagnoses of depression and anxiety who were prescribed antianxiety and antidepressant medications did not have individualized care plans that identified target behaviors or non-pharmacological interventions. The care plans contained general statements and interventions that were not specific to the individual residents' symptoms or needs. Physician orders for monitoring behaviors were also not tailored to the residents, and documentation did not describe specific signs or symptoms of anxiety or depression. The facility's own policy required that care plan goals and objectives be resident-oriented, behaviorally stated, measurable, and based on comprehensive assessments. However, the care plans reviewed did not meet these standards, as they failed to include individualized, measurable goals and interventions for the residents' identified conditions. Staff interviews further confirmed that the care plans were not personalized and did not provide clear guidance for addressing the residents' specific needs.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors identified that the facility failed to provide food at an appetizing and safe temperature to four residents, as evidenced by resident interviews, staff interviews, observations, and policy review. Multiple residents who ate meals in their rooms reported that their food was often delivered cold, with some stating this occurred several times per week. During a lunch meal service observation, food temperatures on a sample tray were measured and found to be below expected standards, with ham at 105°F, cauliflower at 124.5°F, and sweet potato fries at 109.6°F. Staff acknowledged these temperatures were lower than anticipated, and the Certified Dietary Manager stated that food should be above 130°F, while the Registered Dietitian indicated a point of service temperature of 140°F was needed. The facility's policy and the FDA Food Code require hot foods to be held at 135°F or above to minimize the risk of foodborne illness. Residents affected included individuals with varying levels of cognitive impairment, as indicated by their BIMS scores, and some with significant medical histories such as renal insufficiency, neurogenic bladder, and history of stroke. Residents described the food as cold, tough, dry, and unappetizing, with one resident specifically noting a sandwich was "cold like the icebox" and missing components. The Administrator was unaware of complaints prior to the survey and expressed uncertainty about the required food temperatures and how to address the issue, despite facility policy and regulatory guidance.
Failure to Implement Effective Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement and follow antibiotic stewardship practices as required. The DON, who recently assumed the role of Infection Preventionist, presented a newly developed antibiotic tracking spreadsheet that did not include any resident-specific information. During the survey, the DON was unable to accurately identify the number of residents on antibiotics, initially stating there was only one resident after checking the electronic chart, despite the Resident Matrix indicating that six residents were on antibiotics at the time. Additionally, the DON was unaware of any tools, such as the McGeer criteria, being used by nursing staff to assess the need for antibiotics. The facility's policy required the Infection Preventionist to oversee infection control and antibiotic use, but these protocols were not being effectively implemented or monitored.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to inform three residents of their options and costs when Medicare Part A coverage ended, as required by federal regulations. For each of the three residents reviewed, documentation showed that the required CMS-10055 form, which explains non-coverage and provides information about appeal rights and private pay options, was not provided. The residents involved had varying degrees of cognitive impairment and were dependent on staff for activities of daily living. Their care plans included restorative programs and therapy services, and their diagnoses included conditions such as parkinsonism, chronic kidney disease, diabetes, and muscle weakness. Despite the transition from Medicare Part A to private pay status, the necessary notifications and explanations were not documented as given to the residents. Staff interviews revealed that the social worker responsible for providing these notifications was new to the position and unfamiliar with the CMS-10055 form. Upon review, the social worker could not locate the form in facility records and acknowledged that residents should be informed about their financial responsibilities and appeal rights when Medicare coverage ends. Facility policy requires completion of the form and resident signature to confirm understanding, but this process was not followed for the residents in question.
Failure to Maintain Clean, Homelike Environment Due to Linen Shortages and Housekeeping Delays
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. In several resident rooms, debris such as pieces of paper, used tissues, and cotton were found scattered on the floors, and beds were left unmade for extended periods. One resident, who was cognitively intact, reported that staff did not assist him in getting ready or making his bed, which prevented him from lying down after breakfast as he preferred. The resident expressed irritation at the lack of assistance and the unmade bed, while his roommate's bed was made by staff. Staff interviews revealed that the lack of clean bottom sheets contributed to the delay in making beds. Certified Nurse Assistants (CNAs) stated that laundry was behind and bottom sheets were not available until after midday, resulting in beds remaining unmade until the afternoon. The laundry assistant confirmed that he was not informed about the shortage of bottom sheets in a timely manner and that linen supplies had been running low in recent weeks. The administrator acknowledged a breakdown in communication among staff regarding linen availability and stated that linen should have been on the beds before lunch. Additional observations showed that some resident rooms remained dirty throughout the day, with floors littered with debris and personal items left out, such as shoes in walking areas. Residents reported that their rooms were frequently dirty and that their beds were often left unmade. When requested, the administration was unable to provide policies related to maintaining a homelike environment, routine housekeeping, or timely application of bed linen.
Failure to Individualize Care Plans for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to properly identify and document non-pharmacological interventions and targeted behaviors in the care plans for three residents who were prescribed high-risk psychotropic medications. For one resident with severe cognitive impairment and diagnoses including anxiety and dementia, the care plan did not include non-pharmacological interventions to be attempted prior to administering opioid or antipsychotic medications, despite the resident receiving these medications multiple times. Staff interviews confirmed that such interventions and targeted behaviors should have been documented in the care plan. Another resident with moderate cognitive impairment and multiple psychiatric diagnoses was prescribed antipsychotic and antidepressant medications. The care plan for this resident did not specify target behaviors related to the use of psychotropic medications or non-pharmacological interventions. Instead, it contained general statements and lacked focus areas with goals and interventions specific to the resident's psychiatric conditions. The facility also failed to individualize the care plan to address the resident's specific needs and behaviors. A third resident with severe cognitive impairment and diagnoses of Alzheimer's, dementia, anxiety, and depression was prescribed several psychotropic medications. The care plan did not identify target behaviors related to the use of these medications or provide person-centered interventions for anxiety and depression. Staff acknowledged that the care plans contained generic statements and did not provide individualized or specific information regarding the use of antipsychotic medications and related behaviors. The facility's policy required care plan goals to be resident-oriented and measurable, but this was not reflected in the care plans reviewed.
Failure to Provide Bed Hold Notice Upon Resident Transfer
Penalty
Summary
The facility failed to provide the required bed hold notice to a resident or the resident's responsible person when the resident was transferred out of the facility. According to the Minimum Data Set, the resident had no cognitive impairment and was transferred to the hospital due to shortness of breath, chest pain, and discomfort, with a request for hospital transfer. Documentation in the Electronic Health Record confirmed the resident's transfer and continued hospital stay, but there was no evidence that a bed hold notice was completed or communicated at the time of transfer. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the bed hold form was not completed as required by both federal regulation and facility policy. The DON acknowledged the absence of documentation and stated that the expectation was for the bed hold to be completed or for the resident's representative to be notified, which did not occur. The facility's policy required residents or their representatives to verify their wish to hold the bed within 24 hours of hospital admission, but this process was not followed for the resident in question.
Failure to Obtain and Follow Physician Orders for Insulin Administration and Catheter Use
Penalty
Summary
The facility failed to obtain and follow physician orders for two residents, resulting in deficiencies in medication administration and device management. For one resident with diabetes mellitus and other comorbidities, staff held fast-acting insulin on multiple occasions without physician-specified parameters or directives. The care plan did not include instructions for insulin use, and there was no documentation that the physician was notified when insulin was withheld. Nursing staff used their own judgment to decide when to hold the insulin, despite the absence of established blood glucose parameters from the physician. Another resident returned from a hospital stay with an indwelling urinary catheter following surgery for a foot fracture. Although the hospital communicated that the resident would return with a catheter, the facility did not obtain a physician order for the device upon readmission. Progress notes documented the presence and function of the catheter, but the clinical physician orders lacked any reference to it. The facility's policy required physician orders for all care and services, including medical devices, but this was not followed in the case of the catheter. Interviews with staff, including the DON and administrator, confirmed that there were no established parameters for holding insulin and that an order for the catheter was not in place prior to the survey. The administrator acknowledged that orders and diagnoses should be entered promptly and that routine orders, especially for catheters, were lacking at the time of the survey.
Failure to Provide Safe and Documented Respiratory Care for Oxygen-Dependent Resident
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident requiring continuous oxygen therapy. The resident, who had a history of heart failure, hypertension, anxiety disorder, obstructive sleep apnea, and pulmonary hypertension, was observed using oxygen at 3 liters per minute via nasal cannula. Multiple observations revealed that the oxygen tubing in use was undated, and there were no documented orders or instructions for changing the oxygen tubing in the resident's Medication Administration Record or Treatment Administration Record. Staff interviews confirmed that oxygen tubing was supposed to be changed weekly, but there was no formal policy in place, and the process was not documented or audited. Further review with the Director of Nursing and the Administrator revealed that the facility did not have a written policy for oxygen tubing changes and relied on manufacturer recommendations, which were inconsistently applied. The lack of documentation and absence of a formal order for tubing replacement contributed to the deficiency, as there was no reliable method to ensure that oxygen tubing was being changed according to professional standards or facility expectations.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A deficiency was identified regarding the provision of appropriate treatment and services to a resident who displays or is diagnosed with dementia. The report indicates that the facility failed to ensure that a resident with dementia received the necessary care and services tailored to their diagnosis and needs. Specific details about the actions or omissions that led to this deficiency, as well as the resident's condition at the time, are not provided in the report.
Failure to Obtain Consent and Provide Education Prior to Influenza Vaccination
Penalty
Summary
The facility failed to ensure that staff obtained signed consents and provided education to residents prior to administering influenza vaccinations. Clinical record reviews for three residents revealed that, despite receiving the influenza vaccine, there was no documentation of signed consent forms or evidence that education regarding the vaccine's benefits and potential side effects had been provided. The residents involved had varying cognitive abilities and medical conditions, including arthritis, dementia, anxiety disorder, cerebrovascular disease, compromised immune systems, and congestive heart failure. Care plans for these residents indicated the need to follow current guidelines for influenza and pneumonia vaccines, but the required documentation was missing from their medical records. Interviews with facility leadership confirmed the lack of proper documentation and education. The DON acknowledged that the immunization process needed improvement and that the current plan to provide consent and education during IDT meetings was not being consistently followed. The administrator expressed a preference for written consent with signatures rather than verbal consent, and the DON admitted that education was not always provided as intended. The facility's policy required that residents or their legal representatives receive information and education about the influenza vaccine prior to administration, with documentation in the medical record, but this was not consistently done.
Failure to Obtain Consent and Provide Education Prior to COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that staff obtained signed consents and provided education to residents prior to administering the COVID-19 vaccine. Clinical record reviews for three residents revealed that, despite receiving the COVID-19 vaccine, their charts lacked documentation of signed consent forms and evidence that education about the vaccine had been provided. These residents had varying cognitive abilities and medical conditions, including arthritis, non-Alzheimer's dementia, anxiety disorder, cerebrovascular disease, compromised immune systems, and congestive heart failure. The facility's policy required that consent be obtained from both the resident and physician, and that education about the vaccine, including benefits and potential side effects, be documented in the resident's permanent medical record. Interviews with facility leadership confirmed the absence of required documentation. The DON acknowledged that the immunization process needed improvement and admitted that while consents were sometimes electronically signed, there was no documentation of education being provided, nor was there a second witness for verbal consents. The Administrator expressed a preference for actual signatures and two witnesses for verbal consents, which was not consistently practiced. These findings indicate that the facility did not follow its own policy regarding COVID-19 vaccination consent and education.
Inadequate Weekend Staffing in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure the safety and well-being of its residents, as evidenced by staffing reviews, interviews, and a Facility Assessment review. The facility, with a census of 56 residents, did not meet its budgeted goal of a Per Patient Day (PPD) of 3, particularly on weekends. Resident #7, who has normal cognition as indicated by a BIMS score of 15, reported that call lights could take longer than 15 minutes to be answered. This delay was attributed to insufficient staffing, especially on weekends, as confirmed by Staff C, a Certified Nursing Assistant, who noted that working on weekends was more challenging due to fewer staff members. The staffing data for Quarter 3 of 2024 revealed a consistent pattern of lower PPD averages on weekends compared to weekdays. For instance, during the week of April 1, the weekday average was 3.29, while the weekend average dropped to 2.69. Similar trends were observed throughout April, May, and June. Staff D, the Scheduler, confirmed the accuracy of the staffing hours and PPD data, noting that there were fewer bath aides and restorative aides scheduled on weekends. The Administrator and Director of Nursing acknowledged the discrepancy in staffing levels between weekdays and weekends, which was reflected in the Facility Assessment updated on April 29, 2024.
Infection Control Deficiencies in PPE Use and Policy Implementation
Penalty
Summary
The facility failed to adhere to standard precautions and enhanced barrier precautions (EBP) in their infection prevention and control practices. Observations revealed that laundry staff were separating laundry without wearing gloves and gowns, despite the presence of COVID-19 positive cases in the facility. Interviews with staff, including the Director of Nursing (DON) and the Administrator, indicated a lack of clarity and adherence to the necessary precautions, with some staff unaware of the requirement to wear gowns during such procedures. Additionally, the facility lacked a comprehensive, written infection prevention control policy. Further deficiencies were noted in the care of a resident with an indwelling catheter. The resident reported that staff did not wear gowns during catheter care, and observations confirmed that a CNA performed catheter drainage without a gown. The resident's care plan did not include information about the catheter or EBP, and staff interviews revealed a lack of education on EBP, particularly concerning the use of gowns during catheter care. The facility's infection preventionist and DON expressed expectations for staff to be trained and follow EBP, especially for residents with indwelling medical devices or wounds. However, the facility did not have an infection control policy that was reviewed annually, as confirmed by the DON. The Centers for Disease Control and Prevention guidelines emphasize the importance of EBP for residents with medical devices or wounds, highlighting the need for proper staff training and availability of personal protective equipment (PPE) at the point of care.
Failure to Obtain DNR Order for Resident
Penalty
Summary
The facility failed to honor a resident's wishes as documented in the Iowa Physician Orders for Scope of Treatment (IPOST) by not obtaining a physician order for a Do Not Resuscitate (DNR) status. Resident #32 had signed an IPOST indicating a DNR status with limited interventions, no artificial nutrition by tube, and transfer to the hospital. However, a review of the resident's clinical physician orders in the electronic medical records revealed that the facility did not have a signed order for the DNR status. Staff A, a social worker, confirmed the absence of a physician order for the DNR status in the electronic medical record. The facility's administrator acknowledged that DNR orders should be reflected in the medical record. The facility's CPR Guideline document stated that DNR orders would be obtained following state-specific guidelines and regulations, but this was not adhered to in the case of Resident #32.
Failure to Provide Advance Notice of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide a resident with the required 48-hour advance notice when Medicare Part A coverage was ending or when all Part B therapies were concluding. This deficiency was identified for one of the three residents reviewed, specifically Resident #146, in a facility with a census of 56 residents. Upon review, it was found that there was no Advanced Beneficiary Notice (ABN) available for Resident #146. During an interview, the Administrator admitted that the facility could not locate a copy of the ABN form for the resident and acknowledged that ABNs should be given with proper notice. Furthermore, a follow-up interview revealed that the facility does not have a specific policy in place for issuing ABNs, although they claim to follow federal regulations.
Failure to Submit MDS Assessment Timely
Penalty
Summary
The facility failed to submit a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one resident, as directed by the Centers for Medicaid and Medicare Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual. The review of the resident's MDS assessment data showed that assessments dated 8/26/24, 8/29/24, and 9/5/24 lacked transmission dates and acceptance. Additionally, the assessment data did not include a Discharge with Return Anticipated Assessment. Staff B, the MDS Coordinator, acknowledged being new to the position and was unsure about the submission requirements. The staff believed that if the MDS page indicated completion, it meant the assessment was done and submitted. The Administrator was aware that MDS submission affected facility reimbursement but lacked specific knowledge of the submission procedures.
Inaccurate MDS Medication Documentation
Penalty
Summary
The facility failed to provide an accurate assessment of residents' medication use as required by the Minimum Data Set (MDS) guidelines. Specifically, for Resident #7, the MDS indicated the use of anticoagulant medications for 7 days during the observation period, despite the absence of any physician's orders for such medications in the resident's Electronic Health Record (EHR). Similarly, for Resident #31, the MDS inaccurately recorded the use of hypnotic and antianxiety medications for 7 days, although there were no corresponding physician's orders in the EHR. These discrepancies were confirmed through staff interviews, where it was acknowledged that the MDS entries did not reflect the actual medication administration. Interviews with facility staff, including the MDS coordinator and the Director of Nursing (DON), revealed an expectation for accurate MDS assessments, yet the facility lacked a specific policy to ensure this accuracy. The Administrator confirmed that the facility relied on the state Resident Assessment Instrument (RAI) manual for guidance but did not have a dedicated policy for MDS accuracy. This oversight contributed to the inaccurate documentation of residents' medication use, as identified during the survey.
Failure to Document Anticoagulant Use in Care Plans
Penalty
Summary
The facility failed to provide a comprehensive care plan for residents using high-risk medications, specifically anticoagulants, for two of the five residents reviewed. Resident #17 and Resident #31 were both prescribed Eliquis, an anticoagulant, to be taken twice daily. However, their care plans did not include documentation of anticoagulant medication use or interventions to guide staff on monitoring for bleeding and bruising, which are critical considerations for residents on such medications. Interviews with facility staff revealed a lack of awareness and understanding regarding the inclusion of anticoagulant medications in care plans. Staff B, the Care Plan Coordinator, admitted to not including Eliquis in the care plans, assuming that staff would refer to the EHR orders page for medication information. The Director of Nursing expressed an expectation for accurate and personalized care plans, while the Administrator acknowledged the absence of a policy for ensuring such care plans, despite following regulations.
Failure to Notify Physician of Resident's Emergency Transfer
Penalty
Summary
The facility failed to notify the physician immediately after a sudden change in a resident's condition and subsequent transfer to the emergency department (ED). The resident, who had diagnoses of heart failure, pulmonary hypertension, respiratory failure, and stroke, experienced sharp chest pain, shortness of breath, and indigestion. Despite the resident's condition and the transfer to the ED, the facility did not immediately inform the primary care physician (PCP) as required by their policy. The PCP was not aware of the situation until the following day, as indicated by the physician's response questioning who authorized the transfer. The facility's policy mandates immediate communication with the resident's physician or delegate in the event of a change in condition or treatment. However, the Director of Nursing (DON) acknowledged that the notification was sent via fax without a recorded time, and the PCP confirmed not receiving a call about the resident's condition or transfer. The DON insisted that the notification was sent but did not address the lack of immediate communication. This oversight in communication was highlighted during staff interviews and the review of the facility's policy.
Failure to Obtain Bed Hold Notifications
Penalty
Summary
The facility failed to obtain bed hold notifications for two residents during their hospital transfers. Resident #1 was sent to the emergency room for treatment of a forehead laceration after a fall, but there was no bed hold form available for review. Similarly, Resident #60 was hospitalized from 8/31/24 to 9/3/24, but the facility did not have a signed bed hold form for this hospitalization. The Administrator acknowledged the absence of bed hold documentation, particularly for weekend hospitalizations, and admitted that the facility does not have a specific policy for bed hold notifications, although they claim to follow regulations.
Failure to Obtain Daily Weights as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of care by not obtaining daily weights for a resident as per physician orders. The resident, who had diagnoses of atrial fibrillation, coronary artery disease, heart failure, and renal insufficiency, was at risk for weight variations due to a history of diuretic use. Despite having physician orders dated 7/25/24 and 7/30/24 for daily weights, the facility did not record weights on multiple consecutive days from 7/25/24 to 8/13/24. The Director of Nursing was unable to provide an explanation for the oversight, acknowledging that daily weights should have been obtained as ordered.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions to reduce hazards and protect residents were followed, resulting in deficiencies for three residents. Resident #1, with moderate cognitive impairment and requiring extensive assistance, fell after being left unattended for a short period. Despite having a call light attached, the resident attempted to stand and fell, later sustaining a femur fracture that required surgery. The facility's call log showed multiple instances of delayed response times, although on the day of the fall, the response time was within 14 minutes. Resident #2, also with moderate cognitive impairment, required assistance with mobility and had a history of falls. Observations revealed that staff did not use a gait belt as required by the resident's care plan, and the resident was seen walking without proper assistance. Staff unfamiliar with the resident's needs were not adequately informed, leading to improper handling and increased risk of falls. The facility's call log indicated several instances of delayed response times for this resident as well. Resident #3, with severe cognitive impairment and a history of multiple falls, was found on the floor multiple times despite interventions in place. Observations showed that staff did not follow care plan interventions, such as using bolsters and turning off the television to decrease stimuli. The facility lacked a protocol for transfers, and the Director of Nursing acknowledged the need for care plan updates and staff adherence to protocols. The facility's fall and call light protocols were not effectively implemented, contributing to the deficiencies observed.
Delayed Call Light Responses for Residents
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, as evidenced by delayed responses to call lights for two residents. Resident #1, who had moderate cognitive impairment and required extensive assistance for daily activities, experienced call light response times ranging from 25 to 35 minutes. A family member reported that the worst delays occurred during meal times when no staff were available in the hall. Facility records showed 41 instances in July where call light responses exceeded 15 minutes for Resident #1's room. Resident #2, also with moderate cognitive impairment and dependent on staff for various activities, reported delays in call light responses, leading the resident to self-transfer to the bathroom. Facility records indicated 18 instances in July where call light responses for Resident #2's room exceeded 15 minutes. Staff interviews revealed that call lights should be answered within 15 minutes, but the Director of Nursing acknowledged that this expectation might not be met during meals. The facility's Call Light Protocol requires all staff to respond to activated call lights and turn off the signal upon entering the resident's room.
Infection Control Deficiency During Resident Care
Penalty
Summary
The facility staff failed to maintain proper infection control practices during personal care for a resident with severe cognitive impairment. The resident, who was always incontinent of bladder and bowel, required assistance from 1-2 staff members for toileting, bed mobility, and hygiene. During an observation, two Certified Nursing Assistants (CNAs) were seen performing personal hygiene and transfer for the resident. Although they initially washed their hands and donned gloves, one of the CNAs did not perform hand hygiene between glove changes throughout the peri care process. The Director of Nursing acknowledged that the standard of care requires hand hygiene between glove changes, although it was noted that in certain situations, such as when a single staff member is managing a large mess, this may not always occur. The facility's handwashing protocol specifies that hand hygiene should be performed before and after direct contact with residents, and before and after removing non-sterile gloves. Despite this policy, the observed practice did not align with the established infection control standards.
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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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