Oskaloosa Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Oskaloosa, Iowa.
- Location
- 605 Highway 432, Oskaloosa, Iowa 52577
- CMS Provider Number
- 165589
- Inspections on file
- 26
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Oskaloosa Care Center during CMS and state inspections, most recent first.
The facility failed to follow a physician’s order for a percussion vest treatment for a cognitively intact resident with multiple complex diagnoses when the ordered nightly treatment was missed due to nursing miscommunication. In addition, after a contracted pharmacy conducted a vaccine clinic providing Shingrix, pneumonia, COVID, Tdap, and flu immunizations, nursing staff did not document which vaccines were given, the injection sites, or any post-vaccination monitoring for adverse reactions for multiple residents, despite facility policy requiring documentation and 72-hour monitoring. One resident later developed a red, raised rash on the upper arm where vaccines had been administered, leading to a new topical medication order and family concerns about the lack of nursing assessment and documentation of the reaction.
Multiple medication administration failures occurred, including missed doses, wrong medications, and delayed tube feedings for several residents. A cognitively intact resident with complex cardiac, respiratory, and neurologic conditions had repeated omissions of seizure medications, Parkinsonism medication, tube feeding, nebulizer treatments, eye drops, nasal spray, and other ordered drugs. A resident with severe cognitive impairment and eye disorders received ear drops in the eye instead of prescribed ophthalmic medications. Another cognitively impaired resident was given another resident’s antihypertensives, potassium, anxiolytic, and gastrointestinal medication after an LPN relied on a nod for identification. A cognitively intact resident with chronic pain and cardiac conditions did not receive a scheduled morning Tramadol dose and later reported significant pain. The DON reported that staff were expected to follow the five rights of medication administration per facility policy.
The facility failed to report all required abuse allegations to the State Agency, including multiple resident-to-resident altercations and a staff-to-resident abuse allegation, despite clear internal reports and witness statements. In one incident, a cognitively impaired resident with dementia and behavioral disturbances slapped two other cognitively impaired residents; several staff witnessed both altercations, but nursing leadership directed staff to document and report only one of the incidents, omitting the second from the state self-report. In a separate incident, a CNA reported that another CNA struck a cognitively impaired, resistive resident on the thigh during care; the reporting CNA described being criticized and threatened by leadership, and the DON later characterized the contact as a pat, concluded it was not abuse, and did not report it to the state. The resident’s EHR contained no documentation of this event, no assessment, no monitoring, and no provider or family notification, despite facility policy requiring that all abuse allegations, including slapping of cognitively impaired residents, be presumed to cause pain and be reported immediately to administration and the State Agency.
A resident with severe cognitive impairment and dementia-related behavioral disturbances became frightened during care when a CNA was reportedly rough and rushed, leading the resident to strike the CNA and the CNA to allegedly hit the resident’s thigh. A CNA reported the incident to the DON and Administrator and described being criticized and told she was overreacting, while being required to retake abuse training. The DON did not report the allegation to the state, did not complete a written investigation, and did not document the incident, assessment, monitoring, or notifications in the EHR, despite facility policy requiring formal investigation steps, documentation, and appropriate notifications for suspected abuse.
A resident with clear documentation as Full Code did not receive CPR when found unresponsive due to staff misreading chart information, confusion over code status indicators, and unfamiliarity with emergency procedures. Staff failed to initiate resuscitation or promptly call 911, and the resident was incorrectly identified as DNR, resulting in no life-saving measures being taken.
A resident with a history of cardiac issues repeatedly complained of chest pain and showed signs of lethargy and decreased responsiveness throughout the day. Despite multiple reports from CNAs, the assigned LPN delayed assessment, did not notify the provider, and failed to document timely interventions. The resident's condition worsened until the evening LPN intervened and sent the resident to the hospital, where a myocardial infarction was diagnosed.
The facility did not provide or document required training in QAPI, compliance and ethics, and infection control for new hires, and failed to ensure annual training for existing staff. Training records were incomplete, and the DON confirmed missing documentation for staff education.
The facility did not ensure that all staff, including new and existing LPNs and CNAs, completed required training on the Quality Assurance and Performance Improvement (QAPI) program. Review of personnel files and training records showed no documentation of QAPI training, and the DON confirmed the lack of such education in staff files.
The facility did not have documentation showing that an LPN and three CNAs completed required infection control training after being hired. Review of personnel files and the in-service attendance calendar showed no evidence of completed training for these staff members, despite the facility's policy that all new hires should receive such training. The DON confirmed that the necessary documentation was missing.
The facility did not have documentation showing that several staff members, including new and existing LPNs and CNAs, completed required compliance and ethics training. Review of personnel files and the in-service attendance calendar revealed that this training was not recorded, and the DON confirmed the lack of evidence for staff education in this area.
Surveyors found that open food items were not consistently dated, covered, or labeled, and food was stored in a manner that could lead to cross-contamination, such as thawing meat above eggs. Additionally, required documentation of dishwasher temperature and sanitizer checks was missing for numerous days, despite facility policies mandating these practices.
A resident without a diagnosis of anxiety or mood disorder received PRN Lorazepam almost daily for several months, exceeding the 14-day limit for PRN psychotropic use. The facility did not respond to pharmacy recommendations to review and discontinue the medication, and failed to ensure a physician's evaluation or appropriate diagnosis, as acknowledged by the DON and Administrator.
A resident receiving daily PRN Lorazepam for anxiety did not have a care plan that addressed the use of anti-anxiety medication, behavior monitoring, or side effect monitoring. Staff and administration confirmed the omission, which was inconsistent with facility policy requiring care plan updates for clinical changes.
A nurse left a cup containing nine oral medications with a resident at a dining table, unsupervised, despite facility policy requiring staff to remain with the resident until all medications are taken. The resident was only approved for unsupervised self-administration of a muscle rub, not oral medications. Interviews confirmed the resident relied on staff for medication administration, and the administrator acknowledged that medications should not be left unattended.
Staff failed to consistently use gloves and perform hand hygiene during perineal care for three incontinent, fully dependent residents. CNAs were observed making direct skin contact with residents' perineal areas after removing gloves or using soiled gloves to touch environmental surfaces, and hand hygiene was not performed as required. Interviews confirmed that glove use is expected throughout perineal care, but the facility could not provide a relevant policy during the survey.
A resident with a severely impaired cognitive status and a history of aggression was involved in multiple altercations with other residents, including grabbing, hitting, and slapping. Despite these incidents, the facility did not adapt the resident's Plan of Care to prevent reoccurrences, as required by care plan instructions. Staff interventions were limited to separating the residents after incidents occurred, and no injuries were noted. Interviews with staff revealed a lack of effective intervention strategies to manage the resident's aggression.
A resident with severe cognitive impairment was subjected to excessive force during a urine sample collection in an LTC facility. Despite exhibiting unusual behavior, the resident's condition was not adequately assessed by the charge nurse. Later, while the assigned nurse was on break, the MDS Coordinator and aides restrained the resident to obtain a urine sample without a physician's order, resulting in distress and bruising. Concerns were raised about the force used and potential re-traumatization, with allegations of documentation being altered.
A LTC facility failed to meet professional standards by falsifying and removing clinical records for two residents. One resident was restrained for a urine sample without a physician's order, leading to bruising, and the documentation was removed. Another resident was pulled from a chair by another resident, resulting in a fall and bruising, but the incident was inaccurately documented as a fall. These actions compromised resident safety and violated regulatory requirements.
The facility failed to adhere to professional standards by falsifying and removing clinical records for two residents. One resident was restrained for a urine sample without a physician's order, resulting in bruising, and the documentation was removed. Another resident was pulled from a chair by another resident, but the incident was inaccurately documented as a fall. The DON denied recollection of the first incident and allegedly instructed staff to misreport the second to avoid police involvement.
A resident with severe cognitive impairment exhibited unusual behavior, including leg shaking and distress. A CNA reported these concerns to an LPN, who dismissed them as normal and did not assess the resident. No assessments were recorded in the clinical records for that day.
The facility inaccurately completed MDS assessments for 77 residents, coding them as having physical restraints due to a misunderstanding by the MDS coordinator. The coordinator believed bed rails on facility beds required coding for physical restraints, despite no residents being physically restrained or having physician orders for such. The facility lacked a policy for MDS coding.
The facility failed to provide adequate staffing in the CCDI unit, leaving only one CNA to supervise residents with severe cognitive impairments during critical times. This led to unsafe situations where residents attempted to ambulate without assistance. Additionally, call light response times were significantly delayed, indicating systemic staffing issues.
A facility failed to conduct a Level 2 PASARR for a resident with severe cognitive impairment and new mental health diagnoses, including anxiety and delusional disorder. Despite the initiation of new psychotropic medications, the facility did not follow its policy to contact the State-designated agency for a Level 2 screen. Staff A confirmed the oversight, citing a lack of a formal process for updating diagnoses or medications.
A resident with arthritis and impaired cognition did not receive recommended restorative exercises, leading to a decline in mobility and increased dependence on staff. Despite therapy recommendations for a restorative nursing program (RNP) to maintain and improve range of motion, strength, and endurance, the resident's participation was inconsistent, as documented in the electronic health record. Staff interviews confirmed the resident's decline and lack of consistent follow-through with the restorative program.
Failure to Follow Treatment Orders and Monitor/Document Post-Immunization Reactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards by not following a physician’s treatment order for a percussion vest and by not documenting or monitoring for adverse reactions to immunizations. One cognitively intact resident with multiple diagnoses, including coronary artery disease, kidney failure, pneumonia, seizure disorder, COPD, respiratory failure, dysphagia requiring a feeding tube, anxiety, depression, and malnutrition, had a physician’s order for a percussion vest to be applied every night at bedtime while the resident was sitting up in a recliner, to be worn for 15 minutes and not to be used while tube feeding was running. A nurse’s progress note documented that the percussion vest treatment was not performed on a specified date due to miscommunication between nurses and assignments. The deficiency also includes the facility’s failure to document and monitor for adverse reactions after a vaccine clinic in which multiple residents received physician-recommended immunizations, including Shingrix, pneumonia, COVID, Tdap, and/or flu vaccines. Electronic health records for these residents did not contain nursing notes specifying which vaccines were administered, the injection sites, or any monitoring for adverse reactions. One resident’s record showed receipt of pneumonia and COVID vaccines, followed several days later by a new order for topical triamcinolone cream for a rash and itching on the left upper arm, with subsequent nursing documentation of a red, raised rash at that site. During a care plan meeting, this resident’s daughters questioned the lack of nursing assessment and documentation of the resident’s reaction to the vaccines. The DON acknowledged that vaccines were administered by a contracted pharmacy and that nursing staff were expected, per facility policy, to document the date, time, and injection site, and to monitor and document adverse reactions and vital signs for 72 hours after immunization, which was not done for the residents who received vaccines.
Multiple Medication Administration Errors and Omissions Involving Several Residents
Penalty
Summary
The deficiency involves multiple failures by nursing staff to administer medications and tube feedings as ordered, resulting in omissions, wrong medications, and delayed treatments for several residents. One cognitively intact resident with significant medical conditions, including coronary artery disease, kidney failure, seizure disorder, COPD, respiratory failure, and dysphagia requiring a feeding tube, had numerous scheduled medications and treatments not administered as ordered over a three‑month period. Review of the MAR showed missed doses of Keppra, water flushes, Fluticasone nasal spray, Systane eye drops, Jevity 1.5 tube feeding, Albuterol nebulizer treatments with pre/post assessments, Carbidopa‑Levodopa, Famotidine, and Fluconazole on multiple dates and times. A nursing incident note further documented that this resident did not receive a scheduled Carbidopa‑Levodopa dose, the Jevity feeding was not started, and a percussion vest treatment was not provided at the ordered time. Another resident with severe cognitive impairment and diagnoses including cancer, non‑Alzheimer’s dementia, COPD, blepharitis, and senile ectropion of the left lower eyelid experienced a medication administration error when an LPN instilled ear drops into the resident’s right eye instead of the ordered ophthalmic medication. The resident immediately reported burning, prompting the nurse to recognize that the wrong medication (ear drops) had been used. This occurred despite existing physician orders for Erythromycin ophthalmic ointment, OcuSoft lid scrub pads, and Systane ophthalmic solution for treatment of ectropion and dry eyes. A third resident with severe cognitive deficits and diagnoses including kidney failure, hypertension, non‑Alzheimer’s dementia, and seasonal allergies received another resident’s medications in error. The LPN prepared medications for a different resident, checked the picture on the eMAR and the table seating chart, and then relied on a nod from the cognitively impaired resident when asked if she was the other resident, leading to administration of Lisinopril, Metoprolol ER, Potassium Chloride, Buspirone, and Omeprazole that were not prescribed for this resident. A fourth cognitively intact resident with A‑fib, heart failure, arthritis, chronic pain, non‑Alzheimer’s dementia, anxiety, and depression did not receive a scheduled morning dose of Tramadol for pain; the LPN documented realizing the omission several hours later, at which time the resident was reporting pain rated 8/10. In interviews, the LPN acknowledged having medication errors, including giving a resident’s medications to the wrong person, and the DON stated that nurses and medication aides were expected to follow the facility’s medication administration policy and the five rights of medication administration.
Failure to Report Resident-to-Resident and Staff-to-Resident Abuse Allegations to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report all allegations and incidents of abuse, including resident-to-resident altercations and staff-to-resident abuse, to the State Agency as required by policy and regulation. Resident #1, Resident #3, and Resident #5 all had severe cognitive impairment documented on their MDS assessments, with diagnoses including dementia, Alzheimer’s disease, anxiety, depression, and behavioral disturbances. On 1/7/26, multiple staff statements documented that Resident #5 slapped Resident #3 on the left arm and then slapped or smacked Resident #1 on the arm/upper body. Staff A, CNA, reported witnessing Resident #5 slap Resident #3 and then smack Resident #1, after which Resident #1 became upset and required redirection. Staff B, CNA, reported witnessing Resident #5 hit Resident #1 but did not see the altercation with Resident #3. Staff C, Social Services, reported seeing Resident #5 slap Resident #3 and then slap or tap Resident #1, describing both contacts as open-handed and not different in nature. Despite these observations, the facility did not fully report the resident-to-resident altercations to the State Agency. Staff A stated she was instructed by Staff C to write a statement only about the altercation between Resident #5 and Resident #3 and to omit the altercation between Resident #5 and Resident #1 because she was told it did not happen, even though she and Staff B both witnessed it. Staff B similarly reported that he was directed by Staff D, RN, not to write a statement about the altercation involving Resident #1 and that the facility was not going forward with reporting that incident. Staff D, RN, stated she was directed by the DON to address the altercations and submit a report to the State Agency but was told it was not necessary to include the incident of Resident #5 hitting Resident #1 because the video camera did not show it. The DON acknowledged that the written statements referenced an altercation between Resident #5 and Resident #1 but did not recall reviewing camera footage or reporting that incident, and the self-report submitted to the State Agency did not include the altercation involving Resident #1. A second deficiency arose from the facility’s failure to report an allegation of staff-to-resident abuse involving Resident #5. Resident #5’s care plan documented dementia with behavioral disturbances, confusion, communication problems, anxiety, and the need for staff to allow adequate time for responses and not rush care. On or about mid-January, Staff E, CNA, reported that while she and Staff F, CNA, were providing care, Resident #5 became scared and resistive, swinging her arms and hitting Staff F on the back. Staff E stated that Staff F then hit Resident #5 on the right thigh, and when confronted, Staff F responded that “it worked.” Staff E reported the incident to the DON and Administrator and requested additional staff presence on the memory care unit. Staff E reported being yelled at by the DON and Administrator, told she was making the facility look bad, overreacting, causing problems, and that sometimes things have to be overlooked. She was sent to the breakroom and told to stay there until the facility heard back from the state, and was later told the state recommended using the incident as a learning experience, with both CNAs to retake Dependent Adult Abuse training. Subsequent interviews revealed conflicting recollections and a lack of required reporting and documentation. Staff D, RN, stated she was informed of the incident by the DON, was told that Staff F would be suspended pending investigation, and later learned the incident had not been reported to the State Agency; when she questioned the DON, she was told it did not need to be reported. Staff E described being threatened with potential loss of certification and prison time for leaving the unit while Staff F still had access to Resident #5. The DON initially stated she was not aware of the January abuse incident but, when prompted, recalled being informed that Resident #5 had hit Staff F and that Staff F had smacked Resident #5 on the leg. The DON described reenacting the event with Staff E, characterizing the contact as more of a pat and concluding it was not abuse, and acknowledged the incident was not reported to the state and that she was not aware of the reporting regulations. Staff F stated Resident #5 had hit her multiple times and that she “patted” Resident #5’s leg to get her attention. Review of Resident #5’s electronic health record showed no documentation of the incident, no head-to-toe assessment, no ongoing monitoring, and no notification of the physician or family, and facility self-reports to the State Agency did not include this allegation. These actions and omissions occurred despite a written facility policy requiring that all allegations of resident abuse, including resident-to-resident physical contact such as slapping, be presumed to cause pain or mental anguish in cognitively impaired residents and be reported immediately to the Administrator and to the State Agency within the specified time frame.
Failure to Thoroughly Investigate Alleged Staff-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of staff-to-resident abuse. Resident #5 had severe cognitive impairment per an MDS assessment, with diagnoses including cancer, non-Alzheimer’s dementia, and dementia with behavioral disturbances. The resident’s care plan required one-person assistance with dressing and personal hygiene, emphasized allowing sufficient time for dressing and undressing, and directed staff not to rush the resident due to communication problems, anxiety, and confusion. On the date of the incident, a CNA (Staff E) reported that another CNA (Staff F) was rough and rushed while providing care, causing the resident to become scared and swing her arms, striking Staff F on the back, after which Staff F allegedly hit the resident on the right thigh. Staff E reported the incident to the DON and Administrator and stated she was told she was overreacting, making the facility look bad, causing problems, and that sometimes things had to be overlooked. Staff E also reported being threatened with potential loss of certification and prison time for leaving the memory unit while Staff F still had access to the resident. Staff D, an RN, stated she was informed by the DON that Staff F would be suspended pending investigation and that the incident was not reported to the state because the DON did not feel it needed to be reported. Staff D also reported that Staff E was required to retake Mandatory Reporter/Dependent Adult Abuse training and was told by the DON she was being dramatic and did not know what dependent adult abuse was. Later, Staff D learned the incident had not been reported to the Iowa Department of Inspections, Appeals and Licensing. When surveyors requested the facility’s investigation, the Administrator and DON initially could not recall the incident, and the DON later acknowledged she had not completed a written investigation. The DON stated she assessed Resident #5 and found no injuries, interviewed both CNAs, and reenacted the event with Staff E, ultimately characterizing the contact as a pat to gain the resident’s attention and concluding it was not abuse. The DON confirmed there were no written witness statements, incident reports, or documented nursing assessments related to the event. Review of the resident’s EHR showed no documentation of the incident, no head-to-toe assessment, no continued monitoring, and no notification to the physician or the resident’s family. This was inconsistent with the facility’s written Abuse Prevention, Identification, Investigation and Reporting policy, which required designation of a management investigator, documentation of the allegation, review of the resident record and assessments, resident assessment for injury, appropriate notifications, and attempts to obtain witness statements and preserve physical evidence.
Failure to Provide CPR Due to Code Status Confusion and Staff Errors
Penalty
Summary
Facility staff failed to provide cardiopulmonary resuscitation (CPR) to a resident who was documented as a Full Code in multiple locations, including the care plan, physician orders, Medication Administration Record (MAR), and Electronic Health Record (EHR). Despite clear documentation of the resident's wishes and physician orders to initiate CPR in the event of cardiac arrest, staff did not carry out resuscitative efforts when the resident was found unresponsive. The failure was due to discrepancies in code status indicators, such as incorrect or missing stickers on the resident's door following a room change, and staff misreading the resident's chart. On the day of the incident, several staff members responded to the resident, who was found slumped in a recliner, diaphoretic, unresponsive, and later displaying agonal respirations. Staff were directed to call 911, verify code status, and obtain the crash cart. However, there was confusion and delay in verifying the resident's code status, with staff incorrectly identifying the resident as a Do Not Resuscitate (DNR) based on misinterpretation of chart information and door stickers. During this period, staff did not initiate CPR, and the resident was pronounced deceased. The ARNP was informed of the death and, based on the incorrect report of DNR status, gave an order to release the body. Multiple staff interviews revealed that the confusion was compounded by staff unfamiliarity with the location of the crash cart and failure to promptly call 911. Staff later discovered, upon further review of the resident's records, that the resident was in fact a Full Code. The deficiency was attributed to miscommunication, lack of familiarity with emergency procedures, and errors in identifying the correct code status, resulting in the failure to provide basic life support as required by the resident's wishes and physician orders.
Failure to Timely Assess and Intervene After Resident Chest Pain Complaint
Penalty
Summary
A deficiency occurred when staff failed to provide timely assessment and intervention after a resident with a significant cardiac history complained of chest pain. The resident had diagnoses including hypertension, nonrheumatic aortic stenosis, and a history of cerebrovascular accidents, and was care planned for altered cardiovascular status. The care plan directed staff to assess for chest pain with every interaction and to notify the provider in the event of a change in condition. On the day in question, the resident exhibited symptoms such as chest pain, lethargy, decreased appetite, and was not acting like herself, as reported by multiple CNAs to the assigned LPN. Despite repeated reports from CNAs that the resident was experiencing chest pain, appeared pale, lethargic, and was not her usual self, the LPN did not perform timely or thorough assessments, delayed taking vital signs until later in the day, and did not notify the provider of the resident's change in condition. The LPN administered an inhaler and acetaminophen but did not document provider notification or further assessment between early afternoon and the evening. The resident's condition deteriorated throughout the day, with staff noting she was difficult to arouse and had not eaten, drunk, or voided. When the evening LPN came on shift and was informed of the resident's status, she immediately assessed the resident, found her unresponsive to verbal stimuli, and called for emergency services. The resident was subsequently hospitalized for a myocardial infarction, as confirmed by elevated troponin levels and hospital records. Interviews with staff and review of facility policy confirmed that the required assessments and provider notifications were not completed in a timely manner, leading to a delay in appropriate care for the resident.
Failure to Implement and Document Required Staff Training
Penalty
Summary
The facility failed to implement and document an effective training program for both new and existing staff members. Personnel file reviews and the in-service attendance calendar revealed that newly hired staff, including an LPN and several CNAs, did not have documentation of completed training in Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and infection control upon hire. Additionally, existing staff members lacked documentation of annual training in QAPI and compliance and ethics. The facility's training records only showed infection control as a topic, omitting QAPI and compliance and ethics. During staff interviews, the Director of Nursing confirmed the absence of additional education documentation in staff files and acknowledged the need to build the training program.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to ensure that all staff, including both new hires and existing personnel, completed mandatory training on the Quality Assurance and Performance Improvement (QAPI) program. Personnel file reviews and the in-service attendance calendar revealed that six staff members, including LPNs and CNAs, did not have documentation of QAPI training upon hire or annually. The facility's training records did not list QAPI as a training topic, and an undated internal document indicated that training was required for all departments but lacked evidence of compliance. During staff interviews, the Director of Nursing confirmed the absence of additional QAPI education in staff files.
Failure to Document Infection Control Training for New Hires
Penalty
Summary
The facility failed to ensure that newly hired staff members completed mandatory infection control training as part of its infection prevention and control program. Personnel file reviews and the in-service attendance calendar revealed that four staff members, including an LPN and three CNAs, did not have documentation of having completed infection control training after their hire dates. An undated facility document indicated that the training program was intended for all departments, including new hires and existing staff, and the in-service calendar listed infection control as a training topic. However, there was no evidence in the staff files to confirm that these new hires had participated in the required training. The Director of Nursing confirmed the absence of additional education documentation in the staff files.
Failure to Ensure Staff Completion of Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that staff completed required training in compliance and ethics, as evidenced by a lack of documentation for both new hires and existing staff. Personnel file reviews and the in-service attendance calendar showed that six staff members, including LPNs and CNAs, did not have records of completing compliance and ethics training upon hire or annually. The in-service attendance calendar did not list compliance and ethics as a training topic, and an undated facility document indicated that training was intended for all departments but did not provide evidence of completion. During an interview, the DON confirmed the absence of additional education in the staff files.
Deficient Food Storage, Labeling, and Dishwashing Documentation
Penalty
Summary
Surveyors observed multiple deficiencies in food storage and sanitation practices within the facility's dietary department. Open food items, including graham cracker crumbs, powdered sugar, and quick rise soft roll mix, were found undated and uncovered. Additionally, a bag of muffin mix was found with an open date several months prior. During inspection of the refrigerator, a full pan of frozen shredded pork was observed thawing on a shelf above eggs, contrary to facility policy and professional standards for preventing cross-contamination. The Dietary Manager confirmed these practices did not meet expectations for food storage and dating. A review of the facility's dishwasher temperature and sanitization chemical strip test log revealed significant gaps in documentation, with numerous days over a three-month period lacking records of required twice-daily checks. Although an observed test of the dishwasher showed appropriate temperatures and chemical levels, the lack of consistent monitoring and documentation was acknowledged by both the Dietary Manager and the Administrator. Facility policies reviewed required proper thawing of meats, dating and labeling of opened foods, and daily monitoring of dish machine sanitization, all of which were not consistently followed.
Failure to Limit PRN Psychotropic Use and Ensure Appropriate Diagnosis
Penalty
Summary
The facility failed to limit the use of a PRN psychotropic medication, specifically Lorazepam, to the required 14-day period and did not ensure that the resident receiving the medication had an appropriate diagnosis. Clinical record review showed that the resident had intact cognition, no diagnosis of anxiety or other mood disorders, and no behavioral or depressive symptoms, yet received Lorazepam regularly over several months. The medication was administered almost daily, far exceeding the 14-day limit for PRN psychotropic use without documented physician rationale for extension. Additionally, the facility did not respond to repeated recommendations from the consulting pharmacist to review and address the ongoing PRN Lorazepam order in accordance with the 14-day rule. The electronic health record lacked documentation of a physician's evaluation or justification for continued use, and the facility's Medication Regimen Review policy, which requires forwarding pharmacist findings to the physician, was not followed. Both the DON and the Administrator acknowledged the absence of an appropriate diagnosis and the failure to act on pharmacy recommendations.
Failure to Include Anti-Anxiety Medication Management in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was prescribed an anti-anxiety medication. The resident, who had intact cognition and multiple medical diagnoses including debility, cardiorespiratory conditions, heart failure, asthma, and respiratory failure, was receiving Lorazepam as needed for anxiety. Despite the ongoing administration of this medication daily since March, the resident's care plan did not include a focus area, goal, or interventions related to the use of anti-anxiety medication, behavior monitoring, or monitoring for possible side effects. This deficiency was identified through clinical record review, staff interviews, and policy review. Both the ADON and the Administrator acknowledged that the care plan was missing required elements related to the resident's anti-anxiety medication. The facility's Clinical Care Management policy requires routine assessment, evaluation, and updating of care plans in response to changes in clinical condition, which was not followed in this case.
Medications Left Unattended During Administration
Penalty
Summary
A deficiency occurred when a nurse failed to follow professional standards during medication administration for a resident with progressive neurological conditions, Parkinson's disease, heart disease, and depression. The resident was assessed as cognitively intact and had a care plan allowing unsupervised self-administration of only a muscle rub, with interventions requiring assessment and documentation of the resident's ability to self-administer. However, during observation, a nurse placed nine oral medications in a cup and left them with the resident at a dining table, unsupervised, before leaving the area. Interviews revealed that the resident's responsible party was unaware of any order for self-administration of pills and stated the resident relied on staff for medication administration. Facility staff confirmed that only the muscle rub was approved for self-administration, and the administrator acknowledged that medications should not be left unattended due to the risk of access by other residents. Facility policy required staff to remain with the resident until all medications were taken, which was not followed in this instance.
Failure to Maintain Hygienic Perineal Care Practices
Penalty
Summary
Surveyors observed that staff failed to perform perineal care in a hygienic manner for three residents who were incontinent and fully dependent on staff for toileting and hygiene. In each case, certified nurse aides (CNAs) either removed gloves and continued care with bare hands, made direct ungloved contact with residents' perineal areas, or used soiled gloves to touch environmental surfaces before continuing care. Specifically, staff were seen disposing of gloves and then making direct contact with residents' buttocks or perineal areas, and in one instance, a privacy curtain was adjusted with soiled gloves before care continued. Hand hygiene was not performed after glove removal and before further resident contact. Interviews with staff, including CNAs and an LPN, confirmed that facility expectations and checklists require glove use throughout the perineal care process. The Director of Nursing acknowledged that bare skin contact during perineal care was inappropriate. Despite requests, the facility was unable to provide a policy regarding perineal care during the survey. The residents involved were all documented as incontinent and fully dependent on staff for hygiene, as reflected in their care plans and Minimum Data Set (MDS) assessments.
Inadequate Supervision Leads to Repeated Resident Aggression Incidents
Penalty
Summary
The facility failed to ensure adequate supervision and prevention of accidents for residents with physical aggression tendencies, leading to multiple incidents involving Resident #3 and other residents. Resident #3, with a severely impaired cognitive status and a history of physical and verbal aggression, was involved in several altercations with other residents, including grabbing, hitting, and slapping. Despite these incidents, the facility did not adapt Resident #3's Plan of Care to prevent reoccurrences, as required by the care plan instructions to keep other residents at arm's length. The incidents involved Resident #3 interacting aggressively with Residents #2, #4, and #7, all of whom also had severely impaired cognitive statuses and required varying levels of assistance with daily activities. These interactions often resulted in physical altercations, such as Resident #3 grabbing Resident #2's arm, backhanding her, and pulling her out of a chair, as well as hitting Resident #4 and striking Resident #7 in the face. Staff interventions were limited to separating the residents after the incidents occurred, and no injuries were noted. However, the facility's failure to implement effective preventive measures and update care plans contributed to the repeated occurrences. Interviews with staff, including the Assistant Director of Nursing and Certified Nurse Aides, revealed a lack of effective intervention strategies to manage Resident #3's aggression. Staff acknowledged the need for increased supervision and potential medication adjustments but did not provide specific interventions to prevent future incidents. The facility's inaction in adapting care plans and implementing adequate supervision measures resulted in ongoing safety risks for residents, as evidenced by the repeated incidents involving Resident #3.
Excessive Force Used in Urine Sample Collection
Penalty
Summary
The facility failed to treat a resident with dignity when excessive force was used to restrain the resident to obtain a urine sample. The resident, who had a severely impaired cognitive status due to non-Alzheimer's dementia, required significant assistance with daily activities and was frequently incontinent. On the day of the incident, the resident exhibited unusual behavior, including leg shaking and signs of distress, which were reported by staff but not adequately addressed by the charge nurse. Later, the resident was taken to the shower room, where further symptoms were noted, and the primary care physician was notified. Despite the physician's instructions to monitor the resident, a urine sample was collected without an order while the assigned nurse was on break. The MDS Coordinator, along with several aides, restrained the resident to obtain the sample, during which the resident was described as erratic and noncompliant, but not combative. The procedure was reportedly distressing for the resident, who was struggling and yelling during the process. Following the incident, staff observed bruising on the resident's arms and legs, raising concerns about the force used during the procedure. The incident was reported to the nurse on the next shift, who documented the bruising and the events leading to it. However, there were allegations of documentation being altered or removed from the resident's record, and concerns were raised about the potential re-traumatization of the resident, who had a history of physical abuse.
Falsification and Removal of Clinical Records in LTC Facility
Penalty
Summary
The facility failed to meet professional standards and practices by falsifying documentation and removing clinical records for two residents. For the first resident, who had severe cognitive impairment and required significant assistance with daily activities, an incident occurred where staff obtained a urine sample without a physician's order. This involved restraining the resident, which led to bruising. A Licensed Practical Nurse (LPN) documented the event thoroughly, but her notes and related incident reports were removed from the resident's clinical record. The Director of Nursing (DON) denied any recollection of the event and claimed no records were removed, despite evidence provided by the LPN. In the second case, a resident with severe cognitive impairment was pulled from a chair by another resident, resulting in a fall and bruising. A Certified Nurse Aide (CNA) witnessed the incident and reported it to a Licensed Practical Nurse (LPN) and a Certified Med Aide (CMA). The LPN documented the incident as a fall, omitting the physical altercation, and later denied being instructed to alter the documentation. The DON was informed of the incident, but the report was inaccurately recorded, potentially to avoid police involvement. Both incidents highlight significant deficiencies in the facility's documentation practices and adherence to professional standards. The removal and alteration of records, as well as the failure to accurately report incidents, demonstrate a lack of integrity in maintaining accurate clinical records and ensuring resident safety. These actions compromise the quality of care and violate regulatory requirements for accurate resident assessments and documentation.
Falsification and Removal of Clinical Records in LTC Facility
Penalty
Summary
The facility failed to meet professional standards and practices by falsifying documentation and removing clinical records for two residents. For the first resident, who had a severely impaired cognitive status and required significant assistance with daily activities, a urine sample was obtained without a physician's order. This was done by restraining the resident to insert a catheter, which resulted in bruising. The Licensed Practical Nurse (LPN) on duty documented the incident thoroughly, but her notes and related reports were removed from the resident's clinical record. The Director of Nursing (DON) denied any recollection of the event and claimed there were no injuries, despite evidence provided by the LPN. In the second case, a resident with severe cognitive impairment was pulled from a chair by another resident, resulting in a fall and a bruise. A Certified Nurse Aide (CNA) witnessed the incident and reported it to other staff members. However, the incident was documented as a fall by a Licensed Practical Nurse (LPN), who later denied being instructed to alter the documentation. The DON was informed of the incident but allegedly instructed staff to document it as a fall to avoid police involvement. Both incidents highlight significant deficiencies in the facility's handling of resident care and documentation. The removal and alteration of records, as well as the failure to accurately report incidents, demonstrate a lack of adherence to professional standards and practices. These actions compromised the integrity of resident care and the facility's accountability in managing resident incidents.
Failure to Assess and Intervene for Resident's Unusual Behavior
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed and provided interventions to maintain their optimal health and well-being. The resident, who had a severely impaired cognitive status with a BIMS score of 0 and required moderate to maximal assistance for daily activities, exhibited unusual behavior, including shaking of the left leg and being very upset. A CNA reported these concerns to an LPN, who dismissed the behavior as normal and instructed the CNA to continue monitoring the resident. Despite repeated reports of concern, the LPN did not assess the resident during the shift, and there were no notes or assessments recorded in the clinical records for the date in question.
Inaccurate MDS Coding for Physical Restraints
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for 77 out of 83 residents, incorrectly coding them as having physical restraints. This error was identified during a facility record review and staff interview. The Resident Matrix document, dated 7/29/24, indicated that 77 residents were recorded as having physical restraints. However, during an interview, the MDS coordinator, Staff K, confirmed that no residents were physically restrained and there were no physician orders for such restraints. Staff K attributed the incorrect coding to her training, which instructed her to code MDS for physical restraints if any facility beds had bed rails. The facility was unable to provide a policy for MDS coding during the survey week.
Inadequate Staffing and Supervision in CCDI Unit
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, particularly in the Chronic Confusion or Dementing Illness Unit (CCDI). Observations revealed that only one Certified Nurses Aide (CNA) was present on the CCDI unit floor during critical times, such as meal services, when resident behaviors were unpredictable and required one-on-one supervision. Staff interviews confirmed that the CCDI unit was frequently understaffed, with CNAs being pulled to assist other units, leaving residents without adequate supervision. This lack of staffing led to situations where residents with severe cognitive impairments and mobility issues attempted to ambulate unsafely without necessary assistance. The report highlighted specific incidents involving residents with severe cognitive impairments who required close supervision and assistance for safe mobility. For instance, one resident with a BIMS score of 3, indicating severe cognitive impairment, attempted to stand and ambulate without her walker, while another resident with unspecified dementia and muscle weakness attempted to leave the dining table without her mobility aid. These incidents occurred while the sole CNA on duty was occupied with other residents, demonstrating the inadequacy of staffing to ensure resident safety and care. Additionally, the facility's call light response times were significantly delayed, with numerous instances of response times exceeding the facility's policy of 15 minutes. The longest recorded response time was over an hour, indicating a systemic issue with staff availability and responsiveness. Interviews with staff and family members further corroborated the concerns about insufficient staffing, with reports of delayed assistance and inadequate supervision contributing to potential safety risks for residents.
Failure to Conduct Level 2 PASARR for Resident with New Diagnoses
Penalty
Summary
The facility failed to submit a Level 2 Preadmission Screening and Resident Review (PASARR) evaluation for a resident with new mental health diagnoses and medication revisions. The resident, identified as having severe cognitive impairment, was documented to have anxiety, depression, and a psychotic disorder. The resident was also on high-risk medications, including antipsychotics, antianxiety, and antidepressants. The last PASARR screening was completed in May 2023, which documented the resident's depression and use of Quetiapine and Sertraline. Despite new diagnoses of anxiety and delusional disorder and the initiation of Risperidone and Lorazepam, the facility did not conduct a Level 2 PASARR. The facility's policy requires contacting the appropriate State-designated agency for a Level 2 screen upon new diagnoses. However, Staff A from social services confirmed that a Level 2 PASARR was not completed, as they believed it was not indicated due to the absence of a status change. There was no formal process in place for updating medical diagnoses or medications.
Failure to Implement Restorative Program for Resident
Penalty
Summary
The facility failed to implement therapy recommendations and provide restorative exercises for a resident with arthritis, weakness, and a history of falling. The resident had moderately impaired cognition and impaired range of motion (ROM) in both upper extremities and one lower extremity. Despite therapy recommendations for a restorative nursing program (RNP) to maintain and improve ROM, strength, and endurance, the resident did not participate in the RNP during the specified periods, as documented in the Minimum Data Set (MDS) assessments. The care plan for the resident, which was revised in March 2024, required assistance with exercises to regain and maintain strength and maximize independence in activities of daily living (ADLs). The plan included a daily RNP with exercises such as active and passive ROM, gait training, and ambulation. However, the electronic health record (EHR) and progress notes revealed inconsistent documentation of the resident's participation in the RNP, with limited instances of group exercise and passive ROM exercises recorded. Observations and staff interviews confirmed the resident's decline in mobility and increased dependence on staff for transfers. Interviews with staff, including the restorative aide and physical therapist, highlighted a lack of consistent follow-through with the restorative program. The resident, who initially ambulated with assistance, experienced a significant decline, requiring a mechanical lift and assistance from two staff members for transfers. The facility's restorative nursing policy emphasized maintaining residents' highest practicable level of functioning, but the documentation and staff reports indicated a failure to adhere to the recommended restorative activities.
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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