Oakview Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Burlington, Iowa.
- Location
- 1212 Indian Hills Drive, Burlington, Iowa 52601
- CMS Provider Number
- 165439
- Inspections on file
- 19
- Latest survey
- June 25, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Oakview Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility did not consistently ensure that providers responded to pharmacist recommendations for gradual dose reductions (GDR) and drug regimen reviews (MRR) for several residents receiving psychotropic and other medications. In multiple cases, documentation of provider review or rationale for declining GDRs was missing, and repeated pharmacist requests went unaddressed, contrary to facility policy.
Three residents, including individuals with respiratory failure, lung cancer, COPD, and cognitive impairment, were not offered or administered the appropriate pneumococcal vaccines as required by CDC guidelines. In each case, either consent was obtained but the vaccine was not given, or the opportunity to consent or refuse was not provided when residents became eligible. The DON reported a lack of knowledge regarding the vaccine schedule and had not proactively identified residents due for immunization.
A resident with a history of stroke and hip fracture, requiring substantial assistance for transfers, requested to be moved from a recliner to a wheelchair. Despite multiple requests and reminders to staff, the resident waited over an hour before being assisted, expressing frustration at not being listened to. Staff interviews confirmed delays and acknowledged that residents should not have to wait this long for assistance, as facility policy requires residents to be treated with dignity and respect.
A resident admitted with a Stage 2 pressure ulcer on the right heel experienced deterioration to a Stage 3 ulcer and developed new pressure ulcers due to inadequate monitoring and intervention by the facility. The facility failed to follow up with a wound clinic, and documentation and communication regarding the resident's condition were insufficient. Staff were inconsistent in their awareness and documentation of the resident's pressure injuries, and facility policies on pressure ulcer prevention and physician notification were not effectively implemented.
The facility failed to revise care plans for three residents, leading to deficiencies in addressing their medical needs. A resident's care plan did not include prophylactic antibiotics despite their use, another resident's wandering concerns were initially omitted, and a third resident's care plan lacked identification of pressure injuries. These oversights were acknowledged by staff and attributed to a new staff member's inexperience in care plan management.
The facility failed to include antiplatelet medication and seizure management in the care plans for two residents. One resident, with moderately impaired cognition, was prescribed Clopidogrel Bisulfate and Aspirin EC, but the care plan did not reflect this. Another resident, with intact cognition, was prescribed Phenytoin Sodium for seizures, yet the care plan did not address this. The MDS Coordinator acknowledged these oversights.
A resident with multiple diagnoses did not receive prescribed medications due to a nurse's error, despite the medications being delivered to the facility. The facility's policy requiring administration per physician order was not followed, leading to a deficiency.
A facility failed to timely initiate antibiotics for a UTI and lacked a clear process for catheter change frequency for a resident with an indwelling catheter. The resident had severely impaired cognition and neurogenic bladder. Inconsistencies in catheter change dates and unclear physician orders were noted, with the Corporate Nurse acknowledging the confusion. Additionally, there was a delay in administering the antibiotic Levofloxacin after a UTI was identified.
A resident with severely impaired cognition did not receive prescribed medications, including a diuretic, antibiotic, and blood pressure medications, due to a failure in delivery from the pharmacy. Facility staff acknowledged issues with prompt medication delivery for new admissions, and documentation indicated the medications were not administered as per physician orders.
Failure to Ensure Timely Provider Response to Pharmacist Drug Regimen Review and Gradual Dose Reduction Recommendations
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews (MRR) and gradual dose reduction (GDR) recommendations made by the consulting pharmacist were consistently and timely addressed by the attending providers for multiple residents. In several cases, the pharmacist identified the need for GDRs for psychotropic and other medications, but the facility was unable to provide documentation that these recommendations were reviewed or acted upon by the prescriber. For example, for one resident with moderate cognitive impairment receiving antidepressant medication, the facility could not produce documentation of a provider's response to a GDR recommendation made in September, and only provided a response dated much later, after repeated requests. Other residents with varying degrees of cognitive impairment and complex medication regimens, including antipsychotics, antidepressants, anxiolytics, and hypnotics, also had GDR recommendations from the pharmacist that were not addressed in a timely manner or lacked provider rationale when GDRs were declined. In some instances, the pharmacist had to repeat GDR requests due to lack of response, and the facility's own documentation confirmed that GDRs for certain residents were not addressed for multiple months. Interviews with facility staff, including the DON, revealed that there was an ongoing issue with providers not documenting rationales for declining GDRs and that unresolved GDRs were sometimes escalated to the medical director or nurse practitioner. Facility policies required that any drug regimen irregularities identified by the pharmacist be reported in writing to the provider, medical director, and DON, and that the provider's response, including rationale for no change, be documented in the medical record. Despite these policies, the facility did not ensure that provider responses to pharmacist recommendations were consistently documented, nor that rationales for declining GDRs were provided, resulting in a deficiency related to the management and oversight of unnecessary medications.
Failure to Offer and Administer Pneumococcal Vaccines per CDC Guidelines
Penalty
Summary
The facility failed to offer or administer the pneumococcal vaccine to three out of five residents reviewed for immunizations, despite having policies in place to assess and vaccinate residents according to CDC recommendations. In one case, a resident with respiratory failure and lung cancer, who had intact cognition, consented to receive the pneumococcal vaccine upon admission, but there was no documentation that the vaccine was administered. The administrator confirmed that staff did not follow through with obtaining an order for the vaccine, despite the resident's family member consenting to vaccination. Another resident with acute and chronic respiratory failure and COPD, also with intact cognition, had previously received both Prevnar 13 and Pneumovax but had not been offered or administered a pneumococcal conjugate vaccine (PCV15, PCV20, or PCV21) as recommended five years after the last dose. The clinical record lacked documentation that the vaccine was offered or refused in the years following eligibility, and the resident only recalled being offered the vaccine on admission and again during the survey process. A third resident, with iron deficiency anemia, moderate intellectual disability, and a history of blood clots, had received Pneumovax but had not been offered a pneumococcal conjugate vaccine after becoming eligible. The resident's guardian had consented to other vaccinations but was not given the opportunity to consent or refuse the pneumococcal conjugate vaccine. The DON, responsible for immunization tracking, reported only recently learning the pneumococcal vaccine schedule and had not run reports to identify eligible residents until prompted by the surveyor.
Failure to Timely Assist Resident with Transfer Request, Compromising Dignity and Respect
Penalty
Summary
A resident with a history of cerebral infarction and a left hip fracture, who required substantial to maximal assistance for transfers and had intact cognition, requested to be moved from her recliner to her wheelchair. During a continuous observation, the resident made her request to a CNA during a water pass, and the CNA responded that she would assist the resident 'in a little bit.' Despite completing the water pass in the same pod, the CNA did not return to assist the resident and instead engaged in other activities, including speaking with staff and helping another resident with a puzzle. The resident remained in her recliner for over an hour after her initial request, repeatedly expressing her desire to be moved and her frustration at not being listened to. When a nurse entered the room, the resident again requested to be moved, and the nurse stated she would inform the CNA. The CNA eventually returned with the non-mechanical lift but again delayed the transfer, telling the resident she would assist her 'in a little bit.' The resident was finally transferred to her wheelchair more than an hour after her initial request. Interviews with staff confirmed that the resident required an assist of two with a non-mechanical lift and that there was only one such lift available for three pods. Staff acknowledged that the resident should not have had to wait so long for assistance and that, according to facility policy, residents should be treated with dignity and respect, including timely responses to their requests. The Director of Nursing also stated that residents should be moved when they request, regardless of how recently they were transferred.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide adequate monitoring, assessment, and intervention for a resident with a pressure ulcer present on admission, leading to the deterioration of the existing ulcer and the development of new pressure ulcers. The resident was admitted with a Stage 2 pressure ulcer on the right heel, which worsened to a Stage 3 ulcer by a later date. The clinical record indicated that the resident experienced pain and was referred to a wound clinic, but the right heel ulcer was not assessed or treated during the first clinic appointment. The facility did not follow up with the clinic, resulting in the right heel ulcer progressing to a Stage 3 with necrotic tissue, and new pressure ulcers developing on the left heel and bilateral buttocks. The facility's documentation and communication regarding the resident's condition were inadequate. The admission assessment failed to identify pressure injuries, and subsequent nursing progress notes lacked detailed assessments and measurements of the wounds. The facility's care plan did not document the presence of pressure ulcers or unhealed skin impairments, and there was a lack of timely notification to the primary care provider about the resident's worsening condition. Staff interviews revealed inconsistencies in the awareness and documentation of the resident's pressure injuries, with some staff unaware of the wounds until the survey. The facility's policies on pressure ulcer prevention, skin checks, and physician notification were not effectively implemented. The policies required timely assessments, documentation, and communication with healthcare providers, but these were not consistently followed. The facility's failure to adhere to its policies and procedures contributed to the resident's pressure ulcers worsening and new ulcers developing, ultimately leading to the resident being sent to the emergency department for suspected cellulitis and sepsis.
Care Plan Deficiencies in Addressing Resident Needs
Penalty
Summary
The facility failed to ensure proper revisions to the care plans of three residents, leading to deficiencies in addressing their specific medical needs. For Resident #45, the care plan did not include the use of prophylactic antibiotics, despite the resident having an indwelling catheter and being on cephalexin for prophylaxis. This oversight was acknowledged by the MDS Coordinator, who confirmed that prophylactic antibiotics should have been included in the care plan. Resident #29's care plan initially failed to address wandering concerns, despite the resident's history of ambulating outside unsupervised and the subsequent placement of a wander guard for safety. The resident expressed a desire to go outside independently, but staff interventions were necessary to ensure safety. The facility's Administrator noted that the staff member responsible for care plans was new, which contributed to the omission of wandering concerns and interventions in the care plan. For Resident #9, the care plan lacked identification of pressure injuries or unhealed wounds, despite the presence of a Stage 2 pressure injury on the right heel and other skin impairments noted in the clinical records. The MDS Coordinator confirmed that wounds and pressure injuries should have been included in the care plan, as per the facility's policy on pressure ulcer prevention. This omission highlights a failure to incorporate necessary interventions into the resident's plan of care.
Care Plan Deficiencies for Antiplatelet and Seizure Management
Penalty
Summary
The facility failed to include the use of antiplatelet medication and seizure management in the comprehensive care plans for two residents. For one resident, the Minimum Data Set (MDS) assessment indicated moderately impaired cognition, and the resident was prescribed Clopidogrel Bisulfate and Aspirin EC. Despite the resident receiving these medications consistently, the care plan did not reflect the use of antiplatelet medication. The MDS Coordinator acknowledged this oversight during an interview. For another resident, the MDS assessment showed intact cognition, and the resident was prescribed Phenytoin Sodium for possible seizure activity. The medication was added following adjustments made in the hospital, and the resident was to follow up with neurology. However, the care plan did not address the seizure disorder or the medications prescribed for it. The MDS Coordinator confirmed that the seizure disorder and related medications should have been included in the care plan.
Medication Administration Error Due to Nurse Omission
Penalty
Summary
The facility failed to administer medications as prescribed for a resident, leading to a deficiency in meeting professional standards of quality. The resident, who was admitted with diagnoses including hypokalemia, paroxysmal atrial fibrillation, hypotension, and adult failure to thrive, did not receive their prescribed medications on the day of admission. The medications included Metoprolol Tartrate for hypertension, Levetiracetam for alcohol use, and Potassium Chloride for hypokalemia. The Medication Administration Record (MAR) indicated that these medications were not administered because they were marked as not available from the pharmacy. Upon further investigation, it was revealed that the medications were indeed delivered to the facility, but the nurse responsible for administering them omitted them in error. The nurse consultant confirmed that the medications were delivered together, and the omission was not due to a delay from the pharmacy. The facility's policy on medication administration, which requires medications to be administered per physician order, was not followed in this instance, resulting in the deficiency.
Deficiency in Timely Antibiotic Initiation and Catheter Change Process
Penalty
Summary
The facility failed to ensure timely initiation of an antibiotic for the treatment of a urinary tract infection (UTI) and did not have a clear process for the frequency of urinary catheter changes for a resident with an indwelling catheter. The resident, who had severely impaired cognition, was noted to have an indwelling catheter due to neurogenic bladder. The care plan included interventions such as assessing the need for the catheter quarterly, maintaining a closed system, and providing catheter care twice daily and as needed. The clinical records revealed inconsistencies in catheter change dates and a lack of clarity in physician orders regarding the frequency of catheter changes. The catheter was changed on various dates, but there was no consistent schedule, and the facility's policy did not specify how frequently catheters should be changed. This lack of clarity was acknowledged by the Corporate Nurse during an interview. Additionally, there was a delay in initiating antibiotic treatment for a UTI. A urine sample was obtained and sent for analysis, but the antibiotic Levofloxacin was not administered until several days later. This delay in treatment was documented in the resident's Medication Administration Record, indicating a gap between the identification of the UTI and the start of antibiotic therapy.
Medication Availability Deficiency for Resident
Penalty
Summary
The facility failed to ensure the availability of necessary medications for a resident, identified as Resident #45, who was one of three residents reviewed for medication availability. The resident, who had severely impaired cognition as indicated by a score of 4 out of 15 on the Brief Interview for Mental Status (BIMS) exam, did not receive several prescribed medications, including a diuretic, an antibiotic, and blood pressure medications, because they were not delivered from the pharmacy. This issue was documented in the Orders-Administration Notes and the Medication Administration Record (MAR) for July 1, 2024, where the medications were marked with a code indicating other/see progress notes. Interviews with facility staff, including the MDS Coordinator, Administrator, and Corporate Nurse, revealed concerns about the promptness of medication delivery for new admissions. The Health Status Note from July 1, 2024, indicated that the resident did not receive any medications that day due to the pharmacy's failure to deliver them, and a call was placed to the pharmacy to address the issue. The facility's policy on Medication Administration, revised in April 2023, states that medications should be administered per physician order, highlighting a deviation from this policy in the case of Resident #45.
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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