Osceola Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Sibley, Iowa.
- Location
- 100 Cedar Lane, Sibley, Iowa 51249
- CMS Provider Number
- 16E761
- Inspections on file
- 15
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Osceola Senior Living during CMS and state inspections, most recent first.
A resident receiving CPAP therapy had no routine cleaning schedule for the CPAP equipment, and staff did not have current CPAP settings available. The resident reported the equipment had not been cleaned since admission and was unsure whether the settings were correct. Orders listed nightly CPAP use, but the settings were not documented, and the care plan did not include cleaning, maintenance, or setting instructions.
The facility did not update physician orders in the electronic health records for two residents with severe cognitive impairment. One resident's PRN lorazepam order was not updated with the correct end date, and another resident's order was similarly mishandled. The facility's policy requires orders to be entered into the computer and notifications made, but these steps were not followed.
A resident with moderate cognitive impairment and heart-related diagnoses did not receive oxygen therapy as per the physician's order to maintain oxygen saturation levels at or above 92%. Despite low oxygen levels during activities, the facility's documentation lacked evidence of appropriate interventions, and the resident's oxygen saturation frequently fell below the prescribed threshold.
A facility failed to include necessary dementia care in the care plan of a resident with Alzheimer's Disease, severe cognitive impairment, stroke, and hypertension. The care plan lacked details on the resident's physical, mental, and psychosocial needs. The DON acknowledged the omission and reported the absence of a policy for dementia care planning.
The facility failed to manage and document psychotropic medications for two residents, omitting these medications from care plans and not specifying targeted behaviors or non-pharmacological interventions. Additionally, a discontinued medication remained in a care plan, and an indefinite prescription lacked an end date. The DON acknowledged these issues and the lack of a policy on unnecessary medications.
The facility failed to follow proper infection control practices for catheter care, as observed with two residents whose catheter bags were hung from garbage receptacles. A CNA did not perform proper hand hygiene during catheter care, using soiled gloves to handle the catheter bag and touching surfaces without removing gloves or sanitizing hands. The facility's policies on catheter care and hand hygiene were not adhered to, as confirmed by the DON.
The facility failed to develop comprehensive care plans for several residents, including those with severe cognitive impairment and multiple diagnoses. Key issues included lack of communication about medication side effects to CNAs, incomplete care plans for high-risk medications, and failure to address specific needs related to dementia and pressure ulcers.
The facility failed to ensure proper infection control practices for a resident on contact precautions, appropriate hand hygiene during feeding assistance, and an annual review of infection control policies. Trash and linen receptacles were incorrectly placed outside a resident's room, and a CNA did not perform hand hygiene between assisting two residents. The facility also lacked a policy for the annual review of infection control procedures.
The facility failed to screen and offer a COVID-19 vaccination to a resident upon admission, as required by their policy. The resident had previously received COVID-19 vaccinations but there was no documentation indicating that the resident was screened or offered a booster dose upon admission.
CPAP Equipment Not Cleaned and Settings Not Available
Penalty
Summary
The facility failed to implement and follow appropriate infection control measures for a resident using CPAP therapy by not establishing or following a routine cleaning schedule for the CPAP equipment and by not providing staff with current CPAP machine settings. Resident #17 had diagnoses including anemia, coronary artery disease, and dementia, and the MDS documented use of a non-invasive mechanical ventilator with a BIMS score of 15. The resident reported that staff had not cleaned the CPAP equipment since admission and stated they did not know whether the CPAP settings were correct. The physician orders showed CPAP use every night but did not include the settings, and the care plan for CPAP therapy did not include instructions for cleaning, maintenance, or settings. The Infection Preventionist and DON confirmed that CPAP and BiPAP equipment should have a regular cleaning schedule and that settings should be available for staff to ensure correct use.
Failure to Update Physician Orders in Electronic Records
Penalty
Summary
The facility failed to adhere to professional standards of care by not updating physician orders in the electronic health records for two residents. Resident #3, who has severe cognitive impairment due to Alzheimer's Disease, stroke, and hypertension, had a physician order for PRN lorazepam updated on February 13, 2025, for a duration of 12 months. However, the electronic record showed the last update on January 5, 2025, with an indefinite end date, indicating a failure to enter the updated order and correct end date. Similarly, Resident #31, diagnosed with dementia, psychotic disorder, and acute kidney disease, also exhibited severe cognitive impairment. The physician reordered PRN lorazepam for this resident on December 31, 2024, for three months, but the electronic record was last updated on September 5, 2025, with an indefinite end date. The facility's policy requires that orders be noted, entered into the computer, and the resident and family notified, but these steps were not followed. The Director of Nursing acknowledged the oversight and indicated that the pharmacy is responsible for entering orders into the electronic health records.
Failure to Administer Oxygen Per Physician's Order
Penalty
Summary
The facility failed to ensure a resident received oxygen therapy as per the physician's order. The resident, who had moderate cognitive impairment and diagnoses including atrial fibrillation, heart failure, and pulmonary hypertension, experienced low oxygen saturation levels during activities. Despite the Certified Nurse Practitioner (CNP) advising to administer oxygen as needed to maintain saturation levels at or above 92%, the resident's oxygen levels frequently fell below this threshold. The clinical records showed that the resident's oxygen saturation levels were consistently below 92% on room air and even while on 2 liters of oxygen via nasal cannula. The facility's documentation lacked evidence of appropriate interventions to maintain the resident's oxygen saturation at the prescribed level. The Director of Nursing acknowledged that the oxygen should have been titrated to meet the order's requirements. The facility's oxygen policy required a physician's order specifying the route and liter flow, and the nurse was expected to monitor and document the resident's oxygen status. However, the records did not reflect adherence to these guidelines, resulting in the deficiency.
Failure to Address Dementia Care in Resident's Care Plan
Penalty
Summary
The facility failed to address the care needs of a resident diagnosed with Alzheimer's Disease in their care plan. The resident, identified as having severe cognitive impairment with a BIMS score of 5, also had diagnoses of stroke and hypertension. Despite these conditions, the care plan did not include information regarding the physical, mental, and psychosocial needs necessary to support the resident's highest practical level of well-being. The Director of Nursing acknowledged the omission and noted that the facility lacked a policy for incorporating Alzheimer's Disease or dementia care into the care plan.
Deficiencies in Psychotropic Medication Management and Care Planning
Penalty
Summary
The facility failed to properly manage and document the use of psychotropic medications for two residents, leading to deficiencies in care planning and medication management. Resident #3, who has severe cognitive impairment due to Alzheimer's Disease, stroke, and hypertension, was prescribed lorazepam, quetiapine, and trazodone. However, the facility did not include these medications in the resident's care plan, nor did it document specific targeted behaviors for their use or non-pharmacological interventions to be attempted prior to medication administration. Similarly, Resident #9, who has no cognitive impairment but suffers from peripheral vascular disease, diabetes mellitus, and stroke, was prescribed lorazepam and trazodone. The facility also failed to include these medications in the care plan and did not document targeted behaviors or non-pharmacological interventions. Additionally, the care plan for Resident #9 still listed sertraline, an antidepressant that had been discontinued, and the facility did not specify an end date for the lorazepam prescription. The Director of Nursing acknowledged these oversights and noted the absence of a policy related to unnecessary medications.
Improper Infection Control Practices in Catheter Care
Penalty
Summary
The facility failed to adhere to proper infection control practices concerning the handling of catheter bags for two residents. Observations revealed that the catheter bags for both residents were improperly hung from garbage receptacles, which is against the facility's infection control policy. Additionally, during the process of emptying a catheter bag, a CNA did not perform proper hand hygiene. The CNA was observed using soiled gloves to handle the catheter bag and then touching various surfaces, including the resident's door, without removing the gloves or performing hand hygiene immediately after removing them. The facility's policy on catheter care and hand hygiene was not followed, as evidenced by the CNA's actions. The policy requires washing hands before and after handling catheters and emphasizes the importance of not allowing the drain tube to touch any surfaces. However, the CNA exited the resident's room with soiled gloves, used hand sanitizer improperly, and failed to maintain a sterile environment. The Director of Nursing confirmed that catheter bags should not be hung from garbage receptacles and that staff should not exit resident rooms without removing PPE and performing hand hygiene.
Deficiencies in Care Plan Development
Penalty
Summary
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical needs. For Resident #9, who had severe cognitive impairment and was prescribed high-risk medications such as Buspirone and Seroquel, the care plan included monitoring for side effects but did not ensure that Certified Nurse Assistants (CNAs) were informed of these side effects. This gap in communication was acknowledged by the Director of Nursing (DON), who confirmed that CNAs do not have access to the Medication Administration Record (MAR) where side effects are listed. Resident #27, who had intact cognition and multiple diagnoses including cancer, heart failure, and diabetes, was prescribed Furosemide, insulin aspart, and morphine sulfate. The care plan only included information about Furosemide and lacked any focus areas or interventions for the insulin and narcotic pain medication, as well as for pain management. This omission was contrary to the facility's policy of developing comprehensive, person-centered care plans. Resident #31, with severe cognitive impairment and diagnoses of dementia and Alzheimer's disease, did not have a care plan that addressed her specific needs related to these conditions. The care plan failed to include proactive measures for identifying symptoms of distress or basic needs such as pain, hunger, and toileting. Additionally, Resident #29, who had multiple diagnoses and a documented stage 2 pressure ulcer, did not have the pressure ulcer included in the care plan. Staff A attributed this to a malfunction in the Electronic Health Records (EHR) system, which had not been resolved at the time of the survey.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure appropriate infection control practices for a resident on transmission-based precautions, proper hand hygiene during assistance with feeding, and an annual review of infection control policies by the medical director. One resident, who had ulcerative colitis and C-diff, was placed on contact precautions and required to stay in her room for 10 days. However, trash and linen receptacles were placed outside the resident's room, contrary to the facility's policy, which required these items to be inside the room for proper disposal of personal protective equipment (PPE). Both the Director of Nursing (DON) and the Infection Preventionist (IP) acknowledged this error during the surveyor's observation. Additionally, a Certified Nurse Assistant (CNA) was observed assisting one resident with lunch and then another without performing hand hygiene in between, which is against the facility's hand hygiene guidelines. The DON confirmed that staff should not assist multiple residents with eating without performing hand hygiene in between. Furthermore, the facility did not perform an annual review of their infection prevention and control policies and procedures, as confirmed by the DON and the new IP. The DON admitted that the facility lacked a policy for the annual review of these procedures.
Failure to Screen and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to screen and offer a COVID-19 vaccination to a resident upon admission, as required by their policy. Resident #5 was admitted to the facility and had previously received COVID-19 vaccinations on 3/8/21 and 4/8/21. However, there was no documentation in the clinical record indicating that the resident was screened or offered a COVID-19 vaccination upon admission, nor was there any record of a booster dose being offered, despite the HHS directive allowing booster doses starting on 9/25/21. The facility's COVID Vaccine Policy, dated 5/3/23, mandates that vaccination preferences be inquired about on admission, with a consent form completed for acceptance or refusal. Additionally, the policy requires that COVID immunizations be offered to each resident per the consulting pharmacist's recommendations, and that the pharmacist document the vaccination in the electronic health record (PCC). The lack of documentation for Resident #5 indicates a failure to adhere to these policies, resulting in the deficiency noted in the report.
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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