Parkview Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfield, Iowa.
- Location
- 2237 Highway 34, Fairfield, Iowa 52556
- CMS Provider Number
- 165306
- Inspections on file
- 23
- Latest survey
- October 9, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Parkview Care Center during CMS and state inspections, most recent first.
Several residents with intact cognition reported ongoing problems with flies in their rooms, using makeshift barriers and fly swatters to cope. Flies were observed in resident rooms and on dining tables during meals, and a large uncovered trash can with food waste was noted in the dining area. Staff and pest control records indicated monthly pest management focused on other pests, and at least one bug trap was not functioning properly, contributing to the persistent fly issue.
During a meal service, the facility did not serve garlic toast as required by the posted menu, and no bread substitute was provided. This affected two residents on therapeutic diets, including one with severe cognitive impairment and another with diabetes, both of whom did not receive the bread component of their meal. Staff interviews confirmed the omission was due to supply issues, and the facility's policy to provide a balanced diet was not followed.
The facility served a vegetable dish that was mushy and heavily seasoned, with staff admitting to not measuring seasonings and residents reporting the food was too peppery or unpalatable. Observations and interviews confirmed that the vegetables did not meet palatability standards, and some residents left the dish uneaten.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with severe cognitive impairment had conflicting code status documentation, with the EHR indicating Full Code and a binder at the nurses' station showing DNR. Staff relied on either source for information, leading to inconsistency in honoring the resident's advance directives.
A resident with severe cognitive impairment and multiple diagnoses experienced a significant weight gain of 22 lbs. over two months. Despite a nutritional assessment noting the gain and recommending changes, there was no documentation that the provider was notified, contrary to facility policy and staff expectations.
A resident with severe cognitive impairment and depression was not provided with an ongoing program of activities based on their preferences and needs. Documentation showed limited participation in exercise and one-on-one visits, with no evidence that other available activities were offered. Staff interviews confirmed activity offerings were restricted due to staffing limitations.
Cognitively impaired, independently mobile residents were left unsupervised in a memory care unit day room where unsecured medications and chemicals, including a staff member's ibuprofen and furniture polish, were accessible. A resident with severe cognitive impairment was observed accessing a cubby containing these items without staff present, contrary to facility policy requiring such hazards to be locked away.
Two residents with severe cognitive impairment and multiple medical conditions were not offered or documented as having received the annual influenza vaccine, despite facility policy and documented consent. The DON was unable to explain the oversight during staff interview.
A resident with severely impaired cognition was observed with torn clothing, exposing an incontinence brief, indicating a failure to ensure proper clothing fit and repair. Staff interviews confirmed the resident's need for new clothing, but there was no formal system to assess clothing needs for cognitively impaired residents. The facility lacked documentation and follow-up with the resident's Power of Attorney regarding clothing needs.
The facility did not employ a Certified Dietary Manager to oversee food and nutrition services. The Dietary Supervisor, responsible for these functions, had not completed the necessary certification despite enrolling in the program over a year ago. The Administrator confirmed the absence of a certified manager, acknowledging the Dietary Supervisor's ongoing certification process.
A resident experienced a decline in health after a fall resulting in a fractured right femur. Despite complaints of stomach discomfort, constipation, and distention, there were delays and inadequacies in care. Staff documented symptoms and attempted interventions such as suppositories and enemas, but faced challenges with medication availability and effectiveness. The resident was found to be impacted, leading to the removal of a large amount of hardened stool by an LPN. The resident continued to experience discomfort and vomiting, with subsequent orders for medications like Zofran and Miralax. As the condition deteriorated, staff observed signs of distress, including a distended abdomen, emesis, altered mental status, lethargy, difficulty staying upright, and mottling in extremities. Vital signs showed low blood pressure and oxygen saturation levels. Despite these signs, there were delays in escalating care, and the resident was sent to the hospital only after a significant health decline.
The facility failed to control a rodent infestation, with staff and residents reporting frequent sightings of mice and droppings in resident rooms and the kitchen area. Despite contacting a pest control provider, the issue persisted, particularly in rooms where residents brought in food and did not allow regular cleaning.
Failure to Maintain Pest-Free Environment in Resident and Dining Areas
Penalty
Summary
The facility failed to maintain an environment free from pests, specifically houseflies, in both resident rooms and the dining area. Multiple residents with intact cognition reported ongoing issues with flies in their rooms, with one resident using a bed pad to block the door crack and another keeping a fly swatter nearby. Residents described frequent encounters with flies, particularly during the summer months, and expressed frustration with the persistent presence of flies. Observations confirmed flies in resident rooms and on dining room tables during meal times. Additionally, a large trash can in the dining area was found uncovered and containing food waste, which could attract pests. Facility records showed that pest control services were provided monthly, but the focus appeared to be on spiders, ants, and mice, with no specific mention of flies as a target pest. Staff interviews revealed that fluorescent light bug traps were in use, but at least one trap in the dining room required a new bulb, and staff relied on visual cues to determine when bulbs needed replacement. The facility's pest control policy required ongoing pest management, window screening, and prompt trash removal, but observations and interviews indicated lapses in these practices, contributing to the continued presence of flies in resident areas.
Failure to Follow Menu and Provide Required Bread Item During Meal Service
Penalty
Summary
The facility failed to follow its posted menu for a lunch meal, resulting in the omission of garlic toast, a required menu item, for all residents, including two residents on therapeutic diets. Observations revealed that during meal preparation and service, dietary staff did not prepare or serve garlic toast as listed on the menu, nor did they provide a bread substitute. Staff interviews confirmed that garlic toast was not served due to supply issues, and no alternative was consistently provided. The Dietary Manager acknowledged the omission and indicated that supply shortages sometimes led to menu substitutions, but these were not always implemented. Two residents were specifically affected: one with severe cognitive impairment and a risk for weight loss, and another with moderate cognitive impairment and diabetes requiring a therapeutic diet. Both residents received their meals without the bread component as specified in the menu, and neither was offered a substitute. The facility's policy requires that residents receive a nourishing, well-balanced diet that meets their nutritional and special dietary needs, which was not met in this instance.
Unpalatable and Overseasoned Vegetables Served to Residents
Penalty
Summary
The facility failed to provide a palatable vegetable during one observed meal, as evidenced by the serving of a California mix vegetable dish that was primarily broccoli, which was soft, mushy, and heavily seasoned with black pepper. Staff interviews revealed that the cook did not follow a measured recipe for seasoning, instead sprinkling and tasting the seasoning blend, which may have resulted in uneven distribution and excessive spice. The dietician confirmed that spices should not have been added unless specified, and the dietary manager acknowledged the difficulty in maintaining proper broccoli texture, noting the possibility of over-seasoning. Resident interviews and observations further supported the deficiency, with one resident requesting additional salt and commenting that the food was already too peppered, while another resident reported the food was often undercooked or overcooked and left the broccoli casserole uneaten due to its mushy appearance. The facility's policy requires that residents receive a nourishing, palatable, and well-balanced diet, but the observed meal did not meet these standards, as confirmed by both staff and resident feedback.
Failure to Follow Professional Standards for Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events leading to the deficiency are provided in the report. No information is given regarding the medical history or condition of any residents at the time of the deficiency.
Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was clear and consistent across all documentation sources. Clinical record review showed that the electronic health record (EHR) listed the resident as Full Code, while a physical document in a binder at the nurses' station indicated Do Not Resuscitate (DNR) status. The resident had diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression, with a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. Staff interviews revealed that staff would check either the EHR or the binder at the nurses' station to determine code status, depending on which was more convenient. Facility policy required that resuscitation status be maintained in the clinical record, but the discrepancy between the EHR and the binder was not addressed prior to surveyor identification.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to notify the physician of a significant weight gain in a resident with diagnoses including edema, non-Alzheimer's dementia, and major depressive disorder, whose cognition was severely impaired. The resident's weight increased from 158 lbs. to 180 lbs. over approximately two months, representing a 13.92% gain. Although a quarterly nutritional assessment noted the weight gain and recommended a reduction in supplement intake, there was no documentation that the provider was notified of the continued weight increase during this period. Staff interviews confirmed that both the RN and DON would expect provider notification in such cases, and facility policy required physician consultation for significant changes in condition or treatment needs.
Failure to Provide Ongoing Activities Program for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the needs and preferences of a resident with severe cognitive impairment, non-Alzheimer's dementia, and major depressive disorder. The resident's care plan and MDS assessment indicated preferences for activities such as listening to music, spending time outdoors, Jewish singing, and socializing with friends from a meditating community. However, documentation showed the resident primarily participated in exercise and one-on-one visits, with limited engagement in other activities. There was a lack of evidence that the resident was offered or participated in a broader range of activities listed on the facility's activity calendar, such as outings, bingo, movies, cooking, crafting, and coffee club. Observations over several days revealed the resident spent significant time sitting or lying in bed, at the dining room table, or watching TV in the day room, with no documentation of participation in preferred or varied activities. Staff interviews confirmed that activity offerings were limited, partly due to staffing constraints, with the Life Enrichment Coordinator also responsible for transportation, reducing time available for activities. The Director of Activities acknowledged the limited activity schedule and expressed a desire to increase the frequency and variety of activities, but at the time of the survey, the deficiency remained.
Unsecured Medications and Chemicals Accessible to Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that medications and chemicals were secured and not accessible to cognitively impaired, independently mobile residents in the memory care unit. Observations revealed that a resident with severe cognitive impairment and impaired decision-making, who was independent with walking, was able to access a cubby in the day room without staff supervision. The resident was observed pulling back a curtain and looking into the cubby while other residents were present and no staff were in the room. The care plan for this resident indicated a tendency to touch various objects and directed staff to allow this only when safe, but staff were not present to supervise. Further review showed that a total of ten cognitively impaired, independently mobile residents were left unattended in the day room at multiple times. During one observation, the cubby was found to contain a staff member's bag with an almost full bottle of ibuprofen and a spray bottle of Old English furniture polish, both of which were accessible to residents. Facility policy required medications and chemicals to be locked and the environment to be free from such hazards, but these protocols were not followed, as confirmed by the DON during an interview.
Failure to Offer and Document Annual Influenza Vaccination
Penalty
Summary
The facility failed to offer and document the administration of an annual influenza vaccine for two residents reviewed for immunization. Clinical record review showed that one resident with diagnoses including obesity, prediabetes, and moderate intellectual disabilities, and another resident with edema, non-Alzheimer's dementia, and major depressive disorder, both had severely impaired cognition. Documentation indicated that a resident representative had consented to the influenza vaccine for one of the residents, but there was no evidence in the records that either resident received the influenza vaccine for the 2024-2025 flu season. The facility's policy required screening and offering of influenza vaccines to all residents, but this was not followed for the two residents identified. During staff interview, the DON was unable to explain how the annual influenza vaccinations were missed for these residents.
Resident Clothing Deficiency
Penalty
Summary
The facility failed to ensure that a resident's clothing fit properly and was in good repair, compromising the resident's right to a dignified existence and personal privacy. This deficiency was observed in a resident with severely impaired cognition, diagnosed with non-Alzheimer's dementia, anxiety disorder, and depression. During an observation, the resident was seen in a wheelchair with a tear in his pants, exposing an adult incontinence brief. Interviews with the resident revealed that his clothes did not fit properly and were torn, indicating a need for new clothing. Staff interviews confirmed that the resident required new clothing and was on a list for clothing donations. However, there was no formal system in place to assess clothing needs for cognitively impaired residents. The facility's social services and nursing staff were responsible for addressing clothing needs, but there was a lack of documentation and follow-up with the resident's Power of Attorney regarding clothing needs. The last documented contact with the Power of Attorney was several months prior, and the resident had last received a clothing donation earlier in the year.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a Certified Dietary Manager to oversee the food and nutrition services, as required. The Dietary Supervisor, who was responsible for these functions, admitted during an interview that she had not completed the necessary education and training to become a Certified Dietary Manager. Although she had enrolled in the certification program over a year ago, she had not finished the coursework. The facility's dietary schedule from July 21, 2024, to August 3, 2024, showed that the Dietary Supervisor was scheduled to work on several days, indicating her active role in the department despite lacking the required certification. The Administrator confirmed the absence of a Certified Dietary Manager, acknowledging that the Dietary Supervisor was still in the process of obtaining her certification.
Assessment and Intervention Delays Following Resident Fall and Health Decline
Penalty
Summary
The facility failed to ensure appropriate assessment and interventions for Resident #1, who experienced a decline in health following a fall resulting in a fractured right femur. Despite Resident #1's complaints of stomach discomfort, constipation, and distention, delays and inadequacies in care were noted. Staff members documented Resident #1's symptoms and attempted interventions such as suppositories and enemas, but faced challenges with medication availability and effectiveness. Resident #1 was found to be impacted, leading to the removal of a large amount of hardened stool by a Licensed Practical Nurse. Despite these efforts, Resident #1 continued to experience discomfort and vomiting, with subsequent orders for medications like Zofran and Miralax. As Resident #1's condition deteriorated, staff observations indicated signs of distress, including a distended abdomen, emesis, and altered mental status. Staff members reported Resident #1's increasing lethargy, difficulty staying upright, and mottling in her extremities. Vital signs were noted to be concerning, with low blood pressure and oxygen saturation levels. Despite these alarming signs, there were delays in escalating care, with Resident #1 only being sent to the hospital after a significant decline in health. The report highlighted instances where staff members noted Resident #1's worsening condition but did not take immediate action to address the severity of the situation.
Rodent Infestation in Facility
Penalty
Summary
The facility failed to provide an effective rodent control program, as evidenced by multiple staff and resident interviews. Staff N, a housekeeper, reported an ongoing mouse infestation, with frequent sightings of mice and droppings in resident rooms, particularly on B-hall. Staff N mentioned that glue traps were ineffective, as mice were chewing on them without getting caught. Staff M, a Certified Nurse Aide, confirmed witnessing a mouse on a resident's lap. Staff O, the Housekeeping Supervisor, noted that the issue began in early February and despite contacting their pest control provider, the problem persisted, especially in rooms where residents brought in food and did not allow regular cleaning. Staff P, the Dietary Supervisor, also reported sightings of mice and droppings in the kitchen area, leading to the placement of glue traps and removal of food from lower shelves. Resident interviews further corroborated the infestation issue. Resident #4, with an intact cognitive status, expressed frustration over frequent mouse sightings in his room and perceived inaction from the staff. Resident #5, also with an intact cognitive status, reported hearing and seeing mice in his room, which was cluttered with trash and belongings. The observations and interviews indicate a significant deficiency in the facility's pest control measures, affecting both the living and dining areas and causing distress among residents.
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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