The Bridges At Ankeny
Inspection history, citations, penalties and survey trends for this long-term care facility in Ankeny, Iowa.
- Location
- 3510 Northwest Ablilene Road, Ankeny, Iowa 50023
- CMS Provider Number
- 165616
- Inspections on file
- 23
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at The Bridges At Ankeny during CMS and state inspections, most recent first.
The facility failed to ensure accurate medication administration for three residents, resulting in wrong medications, duplicate dosing, and under-dosing. One resident who had recently changed rooms was given another resident’s full set of medications when an RN pulled drugs from the wrong cart slot and did not verify the name or compare the bubble packs to the MAR, leading to hypotension and bradycardia. A second resident with dementia received a double dose of Donepezil when an RN administered the medication but did not document it or secure it on the cart, and a CMA later found the unsigned dose and administered it again. A third post-surgical resident with rectal cancer and severe pain received only half of the ordered Tramadol dose for several days because staff followed the pharmacy bubble pack labeling instead of the physician’s 100 mg order in the electronic record and failed to reconcile the discrepancy between the pack and the MAR.
Unsanitary food service areas and improper glove and bare-hand food handling were observed in multiple kitchenette and dining service areas. Debris, dried residue, and dirty equipment were found on counters, shelves, freezers, steam tables, microwaves, and ice scoop holders, and the DON reported no cleaning schedules were in place for the kitchenettes. During meal service, a Dietary Aide/Cook used the same gloves across multiple tasks, touched meal slips, utensils, refrigerator and cart handles, and a ready-to-eat hot dog bun without sanitizing hands between glove changes. CNAs were also observed touching unsanitary surfaces and making direct bare-skin contact with residents' food before serving it.
Infection control failures involved a resident on COVID-19 droplet precautions, where a staff member wore an N95 over a surgical mask and later left the room still wearing the surgical mask, plus repeated lapses in sanitizing mechanical lifts between residents. The facility also lacked documentation of BiPAP filter cleaning or replacement for a resident with pneumonia, sepsis, and OSA, even though the resident was observed using the device and staff reported only filling the water tank.
Failure to obtain BiPAP orders and accurate settings for a resident with pneumonia, sepsis, and OSA. The MDS and care plan did not reflect BiPAP use, yet the admission assessment documented BiPAP use and the resident was observed using the device in her room. The resident said staff only filled the water tank, while an RN stated BiPAP use should be supported by an order with documented care and on/off times; the ADON, Administrator, and RDCS said they were unaware the resident was using BiPAP.
Failure to Post Daily Nurse Staffing Information: The facility did not post the daily nurse staffing report for multiple days, and the posting remained dated with an old form in a prominent location near the administrator's office. The Staffing Coordinator said she was responsible for the posting but was unsure how to complete it after a new payroll system was implemented because it no longer had an option to print the required form. The Administrator was unaware the report had not been posted daily and agreed it had not been posted since the end of February.
Staff failed to administer medications as ordered and on time for several residents, with multiple medications—including pain management, insulin, anticoagulants, and others—being given hours after the scheduled times. Audit reports and staff interviews confirmed the delays, and the DON verified the late administrations.
The facility did not respond to resident call lights within the required 15-minute timeframe, with multiple instances of call lights remaining unanswered for extended periods, including up to three hours. Family members and residents reported repeated delays, and staff confirmed that inadequate staffing contributed to the problem. The administrator was aware of ongoing issues, and Resident Council Notes documented repeated complaints about slow call light responses.
Staff failed to consistently follow infection control protocols during an outbreak and while two residents were on enhanced barrier precautions, including not sanitizing equipment after it fell on the floor, not using barriers when placing items in resident rooms, and not always wearing proper PPE. Leadership and staff interviews confirmed ongoing issues with infection control compliance.
A resident receiving hospice care for brain and lung cancer was prescribed oral inhalers and instructed to rinse her mouth after each use. She refused the oral rinses, resulting in stomatitis, but the care plan did not address either the stomatitis or her continued refusal to rinse.
A resident with multiple health conditions and moderate cognitive impairment did not receive proper perineal care after incontinence. Staff cleaned only a limited area, failed to cleanse the vaginal, buttocks, and thigh regions as required, and did not follow facility policy for perineal hygiene. The resident also reported dissatisfaction with previous care related to toileting assistance.
The facility failed to provide sufficient staff to ensure call lights were answered within 15 minutes, with reports of delays up to 60 minutes. Observations and interviews revealed significant staffing shortages, particularly on weekends and during increased admissions, leading to long wait times for resident assistance. Family members and staff expressed concerns about the impact of reduced staffing levels following a change in ownership.
A facility failed to involve a resident and their representative in regular care conferences, holding only two in the past year despite the resident's preference for family involvement. The resident, with a history of stroke, cancer, and dementia, had severely impaired decision-making skills. The social worker confirmed the last care conference was held months ago and could not explain the lack of subsequent meetings.
The facility failed to provide adequate oral hygiene care for two residents as per their care plans. One resident, with a history of stroke and dementia, was dependent on staff for oral care, but documentation showed significant lapses, especially during evening shifts. Another resident, with anxiety and dementia, required assistance and encouragement for oral hygiene, yet documentation was inconsistent, with no records for February. Staff interviews highlighted issues with documentation and care provision.
A resident with dementia and high fall risk was found in a bed left in a high position without supervision, contrary to the facility's Fall Prevention Policy. The resident's care plan required supervision and a safe environment due to cognitive impairment and fall risk, but staff failed to maintain the bed in a low position, as observed by a surveyor.
A resident with end-stage renal disease and a suprapubic catheter did not receive complete incontinence care as per facility policy. During an observed procedure, staff failed to cleanse the resident's groin, penis, scrotum, and thighs, despite the presence of the Director of Nursing. The facility's Perineal Care policy was not followed, leading to a deficiency in care.
A resident with intact cognition fell over her walker and was assisted by CNAs, but the incident was not documented in a timely manner. The nurse on duty, who was already on a final warning for documentation failures, did not record the fall until instructed by management. The facility's policy requires incidents to be documented in the EHR before the end of the shift, which was not followed, leading to a deficiency in maintaining accurate medical records.
A LTC facility failed to follow professional standards for medication administration in two incidents. In one case, an LPN intended to administer medication found unattended near a resident without proper verification. In another, a resident with intact cognition had medications left on their bedside table, including a discontinued drug. The facility's policy requires safe and timely administration, which was not followed.
The facility failed to provide consistent restorative exercises for three residents with limited ROM and mobility issues due to staffing shortages. Despite therapy recommendations, the prescribed exercises were rarely completed, as the restorative aide was frequently reassigned to other duties. This led to a deficiency in care for residents with conditions such as CVA, hemiplegia, and dementia.
A facility failed to ensure staff used Enhanced Barrier Precautions (EBP's) for a resident with a suprapubic catheter. Despite the presence of an EBP sign and available protective equipment, staff did not wear gowns during high-contact care activities. Interviews confirmed that EBP's were required for residents with catheters, and the facility's policy mandated gowns and gloves to prevent the spread of MDRO's.
The facility failed to ensure safe transfer procedures, resulting in incidents where residents were injured due to improper use of equipment and lack of supervision. A resident fell from a weight chair due to a dislodged wheel, another was transferred without engaging lift stability legs, and a third fell from a mechanical lift due to unsecured straps.
The facility failed to provide sufficient nursing staff, resulting in delayed call light responses and unmet resident needs. Observations showed call lights unanswered for over 30 minutes, and interviews with residents and staff confirmed understaffing issues. Staff reported working short, with inadequate support for residents requiring two-person assistance. Despite management's belief in adequate staffing, the facility's assessment did not align with actual resident needs, leading to prolonged wait times and insufficient care.
The facility failed to accurately assess their resident population and resource needs, leading to inadequate staffing and delayed care. The facility assessment did not reflect the actual resident census, and interviews revealed significant delays in response times and insufficient CNAs to assist with ADLs and meals. The Executive Director acknowledged inaccuracies in the assessment, attributing them to a clerical error by the former Administrator.
A resident with liver cirrhosis and cancer, dependent on staff for toileting, was not assisted in a timely manner after requesting help for a bowel movement. Despite the care plan and facility policy requiring staff assistance, the CNA and CMA did not provide the necessary help, and the resident's need was not communicated during shift handoff, resulting in a deficiency in maintaining the resident's dignity.
The facility failed to maintain a clean and homelike environment in the memory care unit dining hall, with food items left on the floor and tables for several days and an overflowing garbage can. Despite expectations for regular cleaning, these conditions persisted, and a family member noted the room's filthy appearance.
A resident with cognitive impairments and a history of falls was not provided with required protective measures, such as Geri-sleeves and fall mats, as outlined in their care plan. Observations showed the resident without these measures, and staff interviews revealed inconsistencies in care plan implementation. The DON acknowledged the oversight, and the facility's policy lacked specific procedures for assistive devices.
A resident with multiple health conditions, including COPD and respiratory failure, was not administered oxygen therapy as ordered. The resident was observed multiple times without the oxygen mask properly in place, leading to low oxygen saturation levels. Family members reported frequent occurrences of the resident being without oxygen, and staff failed to respond promptly during a shift change. The facility's Director of Nursing expected more frequent assessments, especially for residents recently returned from the hospital.
A facility failed to provide a nourishing diet to a resident who chose to eat in her room, leading to a deficiency. Meal service was delayed and chaotic, with no room trays provided to residents confined to their rooms. Staff interviews revealed systemic issues in meal delivery, with the kitchen often forgetting room trays and nursing staff responsible for serving residents on modified diets. The facility's policy required meals to be served according to residents' needs and preferences, which was not followed.
A CNA failed to follow infection control practices while caring for a resident with a catheter, who was on Enhanced Barrier Precautions. The CNA did not wear gloves when handling a graduate container with urine, contrary to facility policy. The ADON expected staff to wear gloves when handling body fluids and to rinse the container after use.
The facility failed to follow infection control practices, including improper handling of a gait belt, lack of barrier use for medical equipment, and incorrect PPE removal. Additionally, a CNA did not wash hands before peri-care and wiped incorrectly, leaving a mechanical sling under a resident without a barrier.
The facility failed to provide discharge and medical information to the receiving health care institution for a resident transferred to the hospital for G-tube placement. The DON confirmed that no transfer form was completed, and staff did not document sending any transfer paperwork or calling the hospital to give a report on the resident's condition. The Administrator confirmed there was no policy for resident transfers to the hospital.
The facility failed to notify the LTC Ombudsman of a resident transfer to the hospital and reentry on the same day, as required by federal regulation. The Administrator confirmed that the facility did not report ED visits to the Ombudsman and lacked a specific ombudsman policy.
A facility failed to include PASRR Level II service recommendations in a resident's Care Plan. Staff interviews revealed a lack of awareness about the need to incorporate PASRR recommendations, and the facility did not have a PASRR policy in place.
The facility failed to develop and implement comprehensive person-centered care plans for three residents. One resident's care plan lacked interventions for dentures and oral care, another resident's care plan did not document fall risks and interventions despite multiple falls, and a third resident's care plan did not include the use of a scoop mattress for positioning.
The facility failed to update a resident's Care Plan to include catheter care after a catheter was inserted due to urinary retention. The ADON confirmed that the Care Plan should have been revised within 24 hours, as per facility policy.
A facility failed to maintain a medication error rate below 5%, with an observed rate of 6.25%. An LPN did not follow proper procedures for insulin administration, leading to incomplete dosing for a resident with diabetes. The ADON, DON, and Corporate Nurse confirmed the expected procedure, but the LPN's actions did not comply with these standards.
A resident with diabetes experienced significant medication errors when an LPN failed to properly administer insulin according to manufacturer instructions and facility policy. The LPN did not hold the insulin pens in the skin for the required time, resulting in insulin leakage and incomplete dosing. Observations and interviews confirmed the proper procedure was not followed.
A facility failed to accurately complete an MDS assessment for a resident with serious mental illness and/or intellectual disability, as indicated by a Level II PASRR. The care plan acknowledged the PASRR status, but the MDS did not, and the facility lacked a specific PASRR policy.
Failure to Ensure Accurate Medication Administration and Dosing for Multiple Residents
Penalty
Summary
The deficiency involves multiple failures in medication administration that resulted in residents not receiving medications as ordered and, in one case, receiving another resident’s medications. One resident with a history of stroke, cognitive communication deficit, and urinary tract infection was involved in a room change. On the morning of the incident, an RN retrieved medications from the medication cart using the room slot labeled for that room, but did not verify the resident’s name on the medication packs or compare the medications to the MAR. The RN popped, crushed, and administered a full set of medications that belonged to a different resident, including several antihypertensives, an anticoagulant, and other medications not prescribed for this resident. Shortly afterward, the resident appeared pale, with head drooping and unable to speak, and was found to have low blood pressure and heart rate. The facility’s investigation documented that the RN had taken medications from the wrong room spot in the cart after the room change and that the investigation lacked documentation of staff or resident interviews about past or present concerns with medication administration. A second deficiency involved another resident with dementia who was cognitively intact per BIMS. On one occasion, a medication (Donepezil 10 mg) arrived from the pharmacy after the CMA had already passed the resident’s morning medications. The RN administered the newly arrived dose but did not immediately sign it out on the MAR and left the medication at the cart between the computer components instead of securing it. While the RN was away in the DON’s office, the CMA, seeing the unsigned medication and not recognizing it had already been given, administered the same medication again and signed it on the MAR. This resulted in a double dose of the medication due to failure to document administration at the time of giving and failure to secure the medication on the cart. A third deficiency involved a resident admitted after digestive system surgery with rectal cancer, anemia, diabetes, a surgical wound, and significant pain. The resident had orders for Tramadol 100 mg PO every 6 hours for pain management, initially PRN and then scheduled. Due to a discrepancy between the physician’s order and the pharmacy-supplied bubble packs, staff administered only 50 mg every 6 hours over several days instead of the ordered 100 mg dose. Documentation showed that the controlled drug receipt forms and bubble pack labels reflected 50 mg tablets, and staff followed the bubble pack directions rather than the computer order. The MAR documented Tramadol 100 mg as given, but only 50 mg was actually administered on multiple occasions. Staff did not compare the bubble pack contents and labeling to the physician’s order in the computer prior to administration, and the error was discovered only after the resident continued to report significant pain and wound dehiscence was noted. Interviews confirmed that nurses and CMAs were expected to follow the 6 rights of medication administration and compare bubble packs to physician orders, but in this case they relied on the bubble pack directions instead of the actual order.
Unsanitary food service areas and improper glove and bare-hand food handling
Penalty
Summary
The facility failed to maintain sanitary and safe conditions in three kitchenettes and six service areas used for food service. During observations, multiple areas contained debris, dried residue, and other visible soil, including crumbs and a white dried substance on a prep counter, debris on a shelf above the counter, dried juice in a reach-in freezer, calcium deposits on a steam table and its lower shelf, a fan on the floor with debris on its guard, a lower shelf covered with a whitish residue, and dried drips on the front of a stainless steel drawer. In the 500 and 600 hall dining room serving area, the microwave contained food debris and the ice scoop holder was dirty. The Dietary Director stated there were no cleaning schedules for the kitchenettes and later said she had scheduled a staff person to work every other week on a cleaning list she compiled. During noon meal service in the 500 and 600 hall kitchenette, a Dietary Aide/Cook handled resident meals while wearing the same pair of gloves across multiple tasks and surfaces. She touched meal slips, utensils, plates, salad bowls, refrigerator handles, cart handles, and a ready-to-eat hot dog bun with the same gloves, removed and replaced gloves without sanitizing her hands, and continued plating meals. She also used scissors to cut meal slips while removing and replacing gloves, and at one point washed her hands for only about five seconds before donning another pair of gloves. The Dietary Aide/Cook acknowledged she had been trained to wear gloves while plating meals and agreed she had touched multiple surfaces before handling the hot dog bun. The Dietary Director stated she encouraged dietary staff not to wear gloves when preparing and serving resident meals. In the 600 hall dining room, CNA staff were observed serving food after touching unsanitary surfaces without hand hygiene and making direct bare-skin contact with resident food. One CNA touched the wheels of a wheelchair and then served meals without washing hands, later served food with her thumb on the eating surfaces of dishware, and directly touched a turkey rueben sandwich before serving it to a resident who consumed it. On another observation, CNAs made direct bare-skin contact with a resident's garlic bread and another resident's food before serving it. Staff interviews confirmed that staff should not touch residents' food with bare hands and should avoid touching the tops of plates to prevent cross contamination. Facility policy stated that bare hand contact with food is prohibited and that food service areas must be kept clean and sanitary.
Infection Control Failures With TBP, Equipment Sanitation, and BiPAP Maintenance
Penalty
Summary
The facility failed to implement Transmission Based Precautions for a resident with COVID-19. Resident #19 had orders for a respiratory panel and portable chest x-ray for cough, shortness of breath, and wheezing, and droplet isolation began after the resident tested positive for COVID-19. The care plan directed staff to follow CDC recommendations and the facility protocol. During observation, a droplet precautions sign was posted at the resident’s door, and a staff member entered the room wearing a yellow gown, gloves, and an N95 mask placed over a surgical mask already on her face. When the staff member exited the room, she removed the N95, gown, and gloves but continued wearing the surgical mask while walking down the hall. The facility also failed to demonstrate proper sanitation of mechanical lifts between residents. On one observation, an unknown staff member moved a mechanical lift from one resident room to another without sanitation. On another observation, a CNA removed a mechanical lift from one room and carried it down the hallway to another room without sanitizing it before use. Staff interviews confirmed that mechanical lifts should be wiped down or sanitized after leaving one resident’s room and before entering another resident’s room, and that cleaning supplies were available at nurse’s stations. The facility’s cleaning and disinfection guidance stated that multi-resident equipment must be cleaned and disinfected after each use. The facility further failed to provide filter changes or cleaning for a resident’s BiPAP machine. Resident #1 had diagnoses including pneumonia, sepsis, and obstructive sleep apnea, and staff observed the resident using a BiPAP device in the room. The resident stated that staff only filled the water tank and that tubing had been ordered. Staff interviews showed confusion about whether the resident was using the BiPAP, while the nursing admission assessment documented BiPAP use. The clinical record lacked documentation of cleaning or replacement of BiPAP filters, despite the facility policy requiring the machine to be maintained according to manufacturer instructions, including cleaning and replacing filters.
Failure to Obtain BiPAP Orders and Accurate Settings
Penalty
Summary
The facility failed to obtain orders and accurate settings for a BiPAP for Resident #1, who had diagnoses of pneumonia, sepsis, and obstructive sleep apnea. The Annual MDS dated [DATE] indicated she did not have a non-invasive mechanical ventilator or use one in the last 14 days, and the care plan initiated on 2/27/26 documented altered respiratory status and diagnoses of pneumonia and obstructive sleep apnea but did not include BiPAP use. In contrast, the Nursing Admission/readmission assessment dated [DATE] documented that Resident #1 used a BiPAP. During observation on 3/09/26 at 2:37 PM, Resident #1 had a BiPAP device on her face and the machine was running. On 3/11/26 at 1:20 PM, a BiPAP machine was in her room on the bedside table, and the resident stated she was on a BiPAP that she takes care of and that staff only filled the water tank for it. Staff F stated a resident on BiPAP should have an order that includes washing the mask, refilling the water reservoir, and documentation of when the BiPAP is on and off. The ADON, Administrator, and Regional Director of Clinical Services stated they were unaware she was using the BiPAP, and the ADON later stated the resident should have had orders for the BiPAP but she was not aware she had one because the family brought it in over the weekend.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily nurse staffing information was posted for 18 of the 31 days reviewed from February 10 to March 12, 2026. An observation on March 10, 2026 at 1:43 p.m. found the staffing posting at the front of the building, beside the administrator's office, was dated February 28, 2026. Behind that form were prior postings for February 10, February 12 through 19, February 24 through 26, and February 28, with no postings found for February 11, February 20 through 23, February 27, or any date after February 28. Additional observations on March 11 and March 12 showed the same February 28 posting still displayed. During interview, the Staffing Coordinator stated she was responsible for posting the daily nurse staffing information and that she printed and posted the forms from the payroll system, but after a new payroll system was implemented on March 1, 2026, she was not sure how to post the required form because the new system did not have an option to print it. The Administrator stated she was not aware the Daily Nurse Staffing Report had not been posted daily since March 1, 2026 and agreed that it had not been posted since February 28, 2026. Facility policy required daily posting of nursing personnel numbers in a prominent, accessible, and readable location.
Failure to Administer Medications According to Physician Orders and Timely Manner
Penalty
Summary
Facility staff failed to administer medications according to physician orders and in a timely manner for four residents. Multiple instances were documented where medications, including pain management, anti-anxiety, anticoagulants, insulin, and other critical drugs, were given significantly later than the times specified in the physician's orders. For example, morphine sulfate, magic mouthwash, and Ativan were administered hours after the ordered times for one resident, while another resident received midodrine, enoxaparin, acetaminophen, and lidocaine patch well past the scheduled administration times. Similar delays were observed for other residents, with medications such as atorvastatin, sucralfate, lidocaine cream, and insulin glargine being administered several hours late. Observations and audit reports confirmed these late administrations, and staff interviews revealed that at least one Certified Medication Aide (CMA) was aware of running behind schedule but did not report the issue. The Director of Nursing (DON) confirmed the accuracy of the documented late medication administrations. The facility had a census of 84 residents at the time, and the deficiencies were identified through record review, observation, and staff interviews.
Failure to Respond to Resident Call Lights in a Timely Manner
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple observations, interviews, and documentation. On several occasions, call lights remained unanswered for extended periods, including instances where a call light was on for 16 to 18 minutes before staff responded, and another instance where a call light was left on for 21 minutes. Family members of two residents reported timing call lights being left unanswered for an average of 32 minutes, with one instance lasting up to three hours. Another family member reported a call light being unanswered for one hour, leading the family to provide care themselves. One resident experienced a fall after attempting to use the bathroom without assistance due to a delayed response to their call light, resulting in feelings of disappointment, sadness, anger, and anxiety. Staff interviews confirmed that call lights were not answered within the facility's 15-minute policy due to insufficient staffing and an inability to meet all residents' needs. Resident Council Notes from several months documented ongoing concerns about delayed call light responses, particularly on the evening shift. The facility's administrator acknowledged awareness of the persistent call light response issues. The facility's policy on answering call lights emphasized the importance of timely responses to residents' requests and needs.
Failure to Follow Infection Control Practices During Outbreak and Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow appropriate infection control practices during an outbreak and when residents were on enhanced barrier precautions. Observations revealed that staff did not sanitize items such as name tags, thermometers, and blood pressure devices after they had fallen on the floor or been used in resident care, and these items were placed on surfaces without barriers or cleaning. Staff also failed to use proper personal protective equipment (PPE) consistently, with some entering resident rooms without appropriate PPE during an outbreak period. One resident with multiple diagnoses, including renal insufficiency and chronic respiratory failure, required assistance with activities of daily living and was on enhanced barrier precautions due to a pressure area on the left heel. Staff were observed providing care to this resident without adhering to proper infection control protocols, such as failing to sanitize equipment and not using barriers when placing items in the resident's room. Additionally, staff were seen using the same gloves to handle multiple items and not sanitizing high-touch objects like call lights after they had been on the floor. Interviews with staff and facility leadership confirmed awareness of ongoing infection control issues, including improper mask use and PPE compliance, especially during the outbreak. Facility policy required staff to use gloves and gowns for high-contact care activities and to place barriers under items set down in resident rooms, but these procedures were not consistently followed. The Director of Nursing and Administrator acknowledged continued problems with infection control practices.
Incomplete Care Plan for Hospice Resident with Stomatitis
Penalty
Summary
The facility failed to maintain a complete and accurate care plan for one resident who was admitted under hospice care with diagnoses of malignant neoplasm of the brain and lung. The resident's treatment included the use of oral inhalers, with instructions to rinse her mouth after each dose to prevent complications. Despite the resident's refusal to rinse her mouth after inhaler use, which subsequently led to the development of stomatitis as documented by the physician, the care plan did not address the stomatitis or the resident's ongoing refusal to perform oral rinses. This omission was identified through clinical record review and staff interview.
Failure to Provide Proper Perineal Care for Dependent Resident
Penalty
Summary
Staff failed to provide proper perineal care to a resident who required substantial assistance with activities of daily living due to diagnoses including renal insufficiency, chronic respiratory failure, muscle weakness, and moderately impaired cognitive skills. During an observed care episode, a CNA assisted the resident after use of a bed pan by cleaning only the mid-gluteal region with a single swipe, neglecting to cleanse the vaginal area, buttocks, or thighs. The soiled brief was replaced with a clean one, but the perineal area was not properly cleaned according to facility policy. When questioned, one staff member did not respond regarding the condition of the brief, while another confirmed it was a little wet. After further questioning, the CNA admitted to not cleansing the resident's vaginal area and then attempted to clean the area by pulling back the clean brief and wiping anteriorly, but replaced the same soiled brief. The resident later expressed dissatisfaction with previous care, stating that a staff member had told her to urinate in her brief rather than providing the requested bed pan. Facility policy requires thorough perineal care, including washing from front to back and cleaning all relevant areas, which was not followed in this instance.
Staffing Shortages Lead to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient staff to ensure call lights were answered within a reasonable amount of time, which is defined as within 15 minutes. Observations and reports from residents, family members, and staff indicated that call lights were often left unanswered for periods ranging from 30 to 60 minutes. The Palatium Care Monitor at the nurse's station showed multiple instances where call lights were left on for extended periods, with some exceeding 60 minutes. This issue was compounded by the facility's inability to provide comprehensive call light reports due to a recent change in the management of the call light system. Interviews with staff revealed that the facility was experiencing significant staffing shortages, particularly on weekends and during times of increased admissions. CNAs and LPNs reported being overwhelmed with the number of residents requiring assistance, especially those needing two-person transfers. The facility's change in ownership was noted to have resulted in reduced staffing levels, further exacerbating the problem. Staff members expressed concerns about the lack of support from management and the difficulty in providing timely care to residents. Family members and residents expressed dissatisfaction with the long wait times for assistance, with some family members advising residents to activate their call lights well in advance of needing help. The Director of Nursing acknowledged the expectation for call lights to be answered within 15 minutes, but the facility's current staffing levels and increased resident admissions made it challenging to meet this standard. The facility's assessment from September 2024 indicated a commitment to maintaining sufficient nursing staff, but the current situation demonstrated a failure to uphold this standard.
Failure to Conduct Regular Care Conferences
Penalty
Summary
The facility failed to involve a resident and/or their representative in care conferences and did not ensure that care conferences were held at least quarterly for a resident with a history of cerebrovascular accident, cancer, and dementia. The resident, who was admitted to the facility with severely impaired decision-making skills, had expressed a preference for family involvement in care discussions. Despite this, only two care conferences were held in the past year, with only one occurring since the facility's change in ownership. The social worker responsible for setting up care conferences confirmed that the last care conference for the resident was held several months ago and was unable to explain why no further conferences had been scheduled since then.
Deficiency in Oral Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate oral hygiene care as directed in the care plans for three residents. Resident #63, who had a history of cerebrovascular accident, hemiplegia, cancer, and non-Alzheimer's dementia, was dependent on staff for oral hygiene. Despite the care plan's directive for oral care to be provided multiple times a day, documentation revealed significant lapses in care, particularly during the evening shifts. Interviews with staff indicated that the resident could become combative during care, but staff attempted to manage this by reapproaching and encouraging the resident. However, the family reported concerns about the resident's oral hygiene, noting instances of bad breath. Resident #25, diagnosed with anxiety disorder, depression, and non-Alzheimer's dementia, required partial or moderate assistance for oral hygiene. The care plan specified that oral care should be provided and documented twice daily. However, documentation showed only sporadic instances of oral care being recorded, with no entries for February. Interviews with CNAs revealed that while the resident required encouragement to perform oral hygiene, there was no record of refusal, suggesting a lack of consistent documentation. The Director of Nursing acknowledged the deficiency in documentation and the expectation for regular oral hygiene care.
Failure to Maintain Bed in Low Position for Resident at Risk of Falls
Penalty
Summary
The facility staff failed to ensure the safety of a resident by not maintaining the resident's bed in a low position, as required by the facility's Fall Prevention Program Policy. The resident, who had diagnoses of dementia, osteoporosis, and anxiety disorder, was observed lying in bed with the bed in a high position without any staff present in the room, hallway, or at the nurse's station. This occurred despite the resident's care plan indicating a need for supervision and a safe environment due to impaired cognitive function and a high risk of falls. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition and dependence on staff for bed mobility and transfers. The facility's policy, updated in 2001, emphasized the importance of maintaining beds at the lowest position to prevent falls, especially for cognitively impaired residents at high risk. However, during the surveyor's observation, the bed was left in a high position, and the Assistant Director of Nursing acknowledged that the bed was higher than preferred, suggesting staff might have been preparing the resident for breakfast. This oversight in maintaining the bed's position posed a potential risk to the resident's safety.
Incomplete Incontinence Care for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to provide complete incontinence care for a resident with significant medical conditions, including end-stage renal disease, obstructive uropathy, and diabetes. The resident, who had a suprapubic catheter and was dependent on staff for toileting, was observed by surveyors during an incontinence care procedure. Staff A and Staff B, both CNAs, transferred the resident from a wet Broda chair to the bed using a mechanical lift. During the procedure, it was noted that the suprapubic catheter was disconnected from the leg bag, which was empty. Staff A reconnected the catheter to the leg bag after cleansing both ends with alcohol swabs. However, the staff failed to perform complete perineal care as per the facility's policy. The Director of Nursing (DON) observed the procedure and confirmed that the staff did not cleanse the resident's groin, penis, scrotum, right hip, and thighs, which are essential parts of complete incontinence care. The facility's Perineal Care policy outlines specific steps for cleaning the perineal area, including washing the urethra, penis, scrotum, and inner thighs, which were not followed. The failure to adhere to these procedures was confirmed by the DON during an interview, highlighting a deficiency in the care provided to the resident.
Failure to Document Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate documentation for a resident who experienced a fall. The resident, who had intact cognition as per her MDS, reported that she fell over her walker while ambulating independently in her room. Despite being assisted by CNAs and assessed by a nurse, the fall was not documented in a timely manner, and the facility staff were initially unaware of the incident when questioned by EMS. The resident's daughter was also not informed of the fall until days later when the resident herself reported it. Interviews with facility staff revealed discrepancies in the documentation process. A CNA confirmed witnessing the fall and notifying the nurse on duty, Staff K, who assessed the resident but did not document the incident immediately. Staff K later entered a late entry record of the fall, but only after being instructed by management. She claimed it was not her responsibility to document the fall as it occurred at the end of her shift. Other staff members, including the DON, confirmed that it was the responsibility of the responding nurse to document incidents in the EHR before the end of their shift. The facility's documentation policy requires that all incidents, including falls, be recorded in the resident's medical record. However, Staff K, who was already on a final written warning for previous documentation failures, did not adhere to this policy. The lack of timely documentation and communication regarding the resident's fall led to a deficiency in maintaining accurate medical records, as required by professional standards.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards and practices regarding medication administration, as evidenced by two separate incidents involving medication being left unattended. In the first incident, a medication cup containing two tablets was found on a dining room table near a resident who was rarely or never understood. The staff member who discovered the medication brought it to the attention of an LPN, who initially disputed the medication belonged to the resident. Despite the surveyor's advice to contact a nurse manager, the LPN intended to administer the medication without proper verification. The medication was later confirmed to match the resident's prescribed potassium and probiotic pills, but the LPN did not report the incident to management until several hours later. In the second incident, a resident with intact cognition was found with a bottle of Zyrtec and a medication cup containing two pills on their bedside table. The resident's husband had brought the Zyrtec from home, despite being informed not to do so. The resident was unsure why the medications were left there or how long they had been present. The medications were identified as Diltiazem and Guaifenesin, with the latter having been discontinued days earlier. The facility's policy requires medications to be administered safely and not left unattended, yet the medications were left on the bedside table without supervision. Both incidents highlight a failure to follow the facility's medication administration policy, which mandates verifying resident identity and ensuring medications are administered correctly and at the right time. The Director of Nursing confirmed that staff are expected to monitor residents during medication administration and report any medication errors promptly. The facility's policy, last revised in 2012, emphasizes the importance of safe and timely medication administration, which was not adhered to in these cases.
Inadequate Restorative Care Due to Staffing Issues
Penalty
Summary
The facility failed to implement therapy recommendations and provide restorative exercises for three residents with limited range of motion (ROM) and mobility issues. Resident #36, who had a history of cerebrovascular accident (CVA), hemiplegia, Alzheimer's Disease, and dementia, was supposed to receive restorative exercises 3 to 6 times per week. However, documentation showed that these exercises were performed only a few times over several months. Interviews with staff revealed that the restorative aide was frequently reassigned to other duties due to staffing shortages, leading to inconsistent delivery of the prescribed restorative program. Resident #54, diagnosed with stroke, hemiplegia, arthritis, and Alzheimer's disease, also experienced a lack of consistent restorative care. The resident's care plan included specific exercises to be performed multiple times a week, but records indicated these were rarely completed. The facility's documentation and staff interviews highlighted that the restorative program was not being followed as intended, with the restorative aide often pulled to cover other staffing needs. Similarly, Resident #63, with a history of CVA, hemiplegia, cancer, and non-Alzheimer's dementia, did not receive the prescribed restorative exercises. The resident's care plan called for passive and active ROM exercises several times a week, but documentation showed minimal completion of these activities. Staff interviews confirmed that the facility's staffing issues led to the neglect of the restorative program, contributing to the deficiency in care for these residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff utilized Enhanced Barrier Precautions (EBP's) when providing care to a resident with a suprapubic catheter. The resident, who had diagnoses of end-stage renal disease, obstructive uropathy, and diabetes, was dependent on staff for toileting and required EBP's due to the presence of an indwelling catheter. Observations revealed that staff did not wear gowns while transferring the resident from a Broda chair to a bed, nor during catheter and incontinence care, despite the presence of an EBP sign and available personal protective equipment in the resident's room. Interviews with staff, including a CNA, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that EBP's were required for residents with tubes such as catheters, and that staff were expected to wear gowns and gloves during high-contact care activities. The facility's policy on EBP's, dated March 25, 2024, outlined the necessity of gowns and gloves to prevent the spread of Multi-Drug Resistant Organisms (MDRO's) during high-contact activities, including transferring residents and providing hygiene care.
Deficiencies in Resident Transfer Procedures
Penalty
Summary
The facility failed to ensure the safe transfer of residents, leading to multiple incidents involving improper use of equipment and lack of supervision. Resident #8, who had severe cognitive impairment and required substantial assistance for transfers, fell while being weighed on a weight chair. The incident occurred when a wheel of the weight chair dislodged, causing the resident to fall and sustain a head laceration and a wrist fracture. The staff did not use a gait belt during the transfer, and the malfunction of the weight chair was not previously identified despite routine maintenance checks. Resident #10, who was fully dependent on staff for transfers and required a mechanical lift, was transferred without engaging the stability legs of the lift. This oversight by the staff during the transfer process posed a significant risk to the resident's safety. Additionally, the staff failed to conduct a time-out to ensure the proper placement of straps before initiating the transfer, which is a critical step in ensuring the safety of mechanical lift transfers. Resident #4 experienced a fall during a mechanical lift transfer when a sling strap slipped off the hook, causing the resident to fall and hit her head. The incident report indicated that the staff did not secure the sling straps properly, leading to the fall. The resident expressed fear of future transfers due to this incident. The facility's documentation highlighted the need for staff training on mechanical lift transfers to prevent such occurrences.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, resulting in delayed response times to call lights and insufficient care. Observations and reports indicated that call lights were not answered within the expected 15-minute timeframe, with some instances exceeding 30 minutes. Interviews with residents and family members revealed that the facility was understaffed, leading to prolonged wait times for assistance, particularly during peak times such as meal services. Residents expressed dissatisfaction with the level of care, citing long waits for help and inadequate staffing levels. Staff interviews corroborated the residents' and families' concerns, with several staff members reporting that they were often short-staffed and unable to meet the demands of the residents. The staffing coordinator and Director of Clinical Services believed the staffing levels were adequate, but staff members, including CNAs and nurses, reported that the facility had cut staff since a new company took over, leading to unsafe conditions and concerns about their ability to provide proper care. The facility's staffing levels were not adjusted to accommodate the increased census and resident acuity, resulting in inadequate care and unmet needs. The facility's assessment and staffing policies were not aligned with the actual needs of the residents, as evidenced by the discrepancies in the reported average census and the actual number of residents. The facility's assessment lacked detailed information for certain halls, and the staffing levels did not reflect the acuity and assistance required by the residents. The Executive Director acknowledged the need for improvement in call light response times and was in the process of understanding the systems in place, but the ongoing staffing issues continued to impact the quality of care provided to the residents.
Inadequate Facility Assessment and Staffing Levels
Penalty
Summary
The facility failed to adequately evaluate their resident population and identify the necessary resources and staffing levels required to provide appropriate care and services. The facility assessment, updated in March 2024, did not accurately reflect the current resident census or the acuity levels across all hallways, particularly omitting information for residents on the 100-200 halls. The assessment indicated an average census range of 50-66 residents, while the actual census was reported to be 87 residents at the time of the survey, with a year-to-date average of 92.9. This discrepancy suggests that the facility did not have an accurate understanding of the resident population, which is critical for determining the appropriate staffing levels and resources needed. Interviews with residents and family members revealed significant delays in response times to call lights, with reports of waiting 20 minutes to an hour for assistance. Family members also noted insufficient staffing, particularly CNAs, which affected the timeliness of care, such as assistance with ADLs and meal service. A CNA expressed concerns about being short-staffed, which impacted their ability to get residents up for meals on time. The Executive Director, who started in August 2024, acknowledged the inaccuracies in the facility assessment and attributed them to a clerical error by the former Administrator. These findings highlight the facility's failure to maintain an accurate and comprehensive assessment of their resident population and resource needs, leading to inadequate staffing and delayed care.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide toileting assistance and care for a resident in a manner that maintained or enhanced dignity. Resident #7, who had diagnoses of liver cirrhosis and cancer, was dependent on staff for transfers and toileting hygiene and had frequent bowel incontinence. The resident's care plan required staff assistance for toileting and keeping the call light within reach. On the day of the incident, the resident informed a CNA that he needed to use the bathroom for a bowel movement. However, the CNA and a CMA, who was just starting his shift, did not assist the resident and instead left the area to check assignments. The staff failed to communicate the resident's need for toileting assistance during the shift handoff, and the resident remained in his wheelchair without assistance. The Assistant Director of Nursing later stated that staff were expected to provide toileting assistance as requested. The facility's policy on supporting activities of daily living required providing care and services for residents unable to carry out ADLs, including assistance with elimination. Despite these policies, the resident's request for assistance was not addressed, leading to a deficiency in maintaining the resident's dignity.
Failure to Maintain Clean Dining Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in the memory care unit dining hall. Direct observations on multiple occasions revealed food items, including dried eggs and smears of jelly, left on the floor and tables for several days without being cleaned. Additionally, a garbage can was observed overflowing with trash from previous dining services. These conditions persisted despite the Certified Dietary Manager's expectation that staff should clean the dining rooms after every meal and perform a deep cleaning after the evening meal. A family member also noted the room's filthy condition, indicating it is often unclean in appearance.
Failure to Implement Care Plan for Resident Safety
Penalty
Summary
The facility failed to adhere to the care plan for a resident with a history of cerebral infarction, anxiety disorder, and non-Alzheimer's dementia, who also exhibited behaviors such as scratching himself and had a history of falls. The care plan, last revised in early August, required the use of Geri-sleeves to protect the resident's skin and fall mats to prevent injury. However, observations on multiple occasions revealed that the resident was not wearing the Geri-sleeves, and fall mats were not present by the bed. Staff interviews and documentation reviews indicated discrepancies in the implementation of the care plan, with the Medication Administration Record (MAR) showing inconsistencies in the documentation of Geri-sleeve application. During an observation, a CNA noticed the absence of Geri-sleeves and fall mats and attempted to address the issue, but the resident was still found without these protective measures the following day. A family member confirmed that the resident was supposed to wear the sleeves but was rarely seen with them. The Director of Nursing acknowledged the absence of fall mats when the resident was moved to another room and emphasized the expectation for staff to follow the care plan. The facility's policy on assistive devices did not provide specific procedures for the use of such equipment, contributing to the deficiency.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen and other respiratory treatments in accordance with physician orders and resident Care Plans for a resident with multiple health conditions, including cerebral infarction, anxiety disorder, non-Alzheimer's dementia, congestive heart failure, respiratory failure, cerebral vascular event, and COPD. The resident was supposed to be on continuous oxygen therapy via a nasal cannula, but the care plan did not specify the ideal oxygen saturation range. Over a period, there were 98 instances where the resident's oxygen saturation was assessed while on room air instead of the ordered continuous oxygen, with the lowest recorded saturation being 84%. On multiple occasions, the resident was observed without the oxygen mask properly in place, leading to low oxygen saturation levels. During one observation, the resident was found with the oxygen mask around his neck and called for help multiple times without staff response, as they were engaged in a shift change. The resident's oxygen saturation was recorded at 79% while wearing a nasal cannula. Family members reported that the resident was often found without oxygen during visits, and images provided showed the oxygen mask improperly positioned. The Director of Nursing stated that staff are expected to assess residents at shift change and more frequently for those recently returned from the hospital.
Failure to Provide Room Trays for Residents
Penalty
Summary
The facility failed to provide a nourishing, well-balanced diet that considered the preferences of a resident, leading to a deficiency in dietary services. During a meal service observation, it was noted that lunch service was delayed and chaotic, with no assistance provided to residents who chose to eat in their rooms or were confined to their beds. The meal service ended without serving room trays to these residents, including one resident who had refused to get up for lunch but wanted to eat in her room. This resident, with intact cognition, reported not receiving a meal and feeling hungry. Interviews with staff revealed systemic issues in meal service delivery, particularly for residents requiring room trays. The Certified Dietary Manager acknowledged that the kitchen staff was not informed of the resident's request for a meal tray. A Registered Nurse confirmed that it was not uncommon for the kitchen to forget room trays, and nursing staff were responsible for serving and feeding residents on modified diets. Another resident reported avoiding eating in her room due to the likelihood of not receiving a room tray, despite having moderately impaired cognition. The facility's policy required residents to receive meals according to their needs and preferences, which was not adhered to in this instance.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility staff failed to adhere to infection prevention and control practices for a resident with a catheter, who was on Enhanced Barrier Precautions (EBP). The resident had a history of liver cirrhosis, cancer, chronic kidney disease, neurogenic bladder, urinary tract infection, and sepsis. During an observation, a Certified Nursing Assistant (CNA) donned a gown and gloves to drain urine from the resident's catheter bag. However, after cleansing the catheter port and removing her gloves, the CNA handled the graduate container with urine without wearing gloves, which was against the facility's policy. The Assistant Director of Nursing (ADON) was present during the observation and later reported that staff were expected to wear gloves when handling body fluids and to rinse the graduate container after use. The facility's policy required all employees to wear gloves when handling body fluids and during high-contact resident care activities, such as indwelling device care. The CNA's actions did not comply with these policies, leading to a deficiency in infection control practices.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff followed infection control practices, leading to potential cross-contamination and spread of infection. One incident involved a Certified Nursing Assistant (CNA) who did not properly handle a gait belt after assisting a resident with a Stage 2 pressure ulcer. The CNA placed the contaminated gait belt in her scrub pocket instead of leaving it in the resident's room, as required by Enhanced Barrier Precautions (EBP). Additionally, a Licensed Practical Nurse (LPN) failed to use a barrier when placing medical equipment on a resident's bed and did not disinfect the plastic bin used to transport medications, which was then placed back on the medication cart and counter without cleaning. Another deficiency was observed when a certified medical assistant exited a resident's room wearing an isolation gown and gloves, which were not removed until reaching the medication cart and nurse's station. This action violated the facility's policy that required PPE to be removed before leaving the resident's room. Furthermore, a CNA did not wash her hands before donning gloves to perform peri-care on a resident and initially wiped from back to front, which is against proper infection control practices. The CNA also left a mechanical sling under the resident without a barrier during the peri-care. The facility's policies on Enhanced Barrier Precautions and Isolation-Transmission Based Precautions were not followed by the staff, leading to these deficiencies. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the lapses in infection control practices during interviews, confirming that the staff did not adhere to the expected procedures for preventing cross-contamination and infection.
Failure to Provide Discharge Information to Hospital
Penalty
Summary
The facility failed to provide discharge and medical information to the receiving health care institution at the time of discharge for a resident who transferred to the hospital. The clinical record review revealed that the resident was transported to the hospital for the placement of a G-tube, but there was no documentation of information sent with the resident. The Director of Nursing (DON) confirmed that no transfer form was completed and that staff did not document sending any transfer paperwork or calling the hospital to give a report on the resident's condition. During an interview, the DON stated that staff should have provided copies of the face sheet, Medication Administration Record (MAR), Physician Orders for Life-Sustaining Treatment (IPOST), and progress notes. Additionally, the DON expected staff to call the hospital to give a report on the resident's condition and document this communication. However, the staff did not follow these procedures, and the Administrator confirmed via email that there was no policy in place for resident transfers to the hospital.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the Long Term Care (LTC) Ombudsman of a resident transfer as required by federal regulation. Specifically, the clinical record for Resident #76 lacked documentation of notification to the LTC Ombudsman when the resident was transferred to the hospital and reentered the facility on the same day. During an interview, the Administrator and Administrator's Assistant confirmed that the facility did not report to the Ombudsman for Emergency Department (ED) visits. Additionally, the Administrator stated via email that there was no specific ombudsman policy in place, and they followed state and federal regulations.
Failure to Include PASRR Recommendations in Care Plan
Penalty
Summary
The facility failed to develop and update the comprehensive Care Plan with Preadmission Screening and Resident Review (PASRR) Level II service recommendations for a resident with a PASRR Level II determination. The resident, who had diagnoses including non-Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder, was admitted to the facility and had a Care Plan that directed staff to follow any specialized services and specialized rehabilitation services recommended. However, the Care Plan lacked the PASRR recommended services, which included ongoing psychiatric medication management, obtaining psychiatric records, rehabilitative services, and community placement supports. Interviews with staff revealed a lack of awareness and understanding regarding the inclusion of PASRR recommendations in the Care Plan. The Social Services staff reported being in the process of making a psychiatric referral but was unaware that PASRR recommendations needed to be included in the Care Plan. The Director of Nursing and Assistant Director of Nursing both indicated that PASRR-related information should be on the Care Plan. Additionally, the facility did not have a PASRR policy in place, as confirmed by the Administrator. The facility's policies on Behavioral Assessment, Intervention, and Monitoring, and Comprehensive Person-Centered Care Plan, indicated that PASRR evaluation reports should be used in resident assessment and care plan development, but this was not followed in this case.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents. Resident #48 was admitted with lower dentures, but the care plan lacked interventions regarding dentures and oral care. Despite family and staff noting issues with the dentures, these concerns were not addressed in the care plan. Staff interviews confirmed that oral care was performed daily, but the care plan did not reflect this, contrary to the facility's policy on comprehensive care plans. Resident #55, who had severe cognitive impairment and a high risk for falls, experienced multiple falls resulting in injuries. The care plan did not document the resident's fall risk or the interventions put in place after each fall. Staff interviews revealed confusion and inconsistencies in updating the care plan, especially after a new company took over the facility's management. The facility's policy requires care plans to be updated within seven days of the MDS assessment and revised as the resident's condition changes, which was not adhered to in this case. Resident #76, who had hemiplegia and hemiparesis, was observed lying on a scoop mattress, which was not documented in the care plan. The DON stated that orders for scoop mattresses are not typically obtained unless used as a restraint, and the facility is a restraint-free environment. The ADON mentioned that the resident's family had requested side rails, which the facility does not allow, and the scoop mattress was offered as an alternative. This intervention was not reflected in the care plan, indicating a failure to document all aspects of the resident's care accurately.
Failure to Update Care Plan for Catheter Insertion
Penalty
Summary
The facility failed to review and revise a resident's Care Plan to meet the resident's needs for catheter care. Resident #26, who had moderately impaired cognition and multiple complex medical conditions, was admitted from a short-term general hospital. The resident's Admission Minimum Data Set (MDS) documented no urinary catheter initially. However, a subsequent order directed staff to insert a catheter due to urinary retention. Despite this, the Care Plan was not updated to reflect the catheter insertion, and it continued to document the resident as an assist of 1 with toileting without any mention of the catheter. During an interview, the Assistant Director of Nursing (ADON) confirmed that the Care Plan should have been revised within 24 hours after the catheter was placed. The facility's policy on comprehensive person-centered care plans also mandates that care plans be revised as residents' conditions change. The failure to update the Care Plan for Resident #26 was acknowledged by the ADON, indicating a lapse in adhering to the facility's policy and the expected standard of care.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with an observed error rate of 6.25%. During a medication administration observation, an LPN administered insulin to a resident with diabetes but did not follow proper procedures. The LPN administered Glargine insulin and Humalog insulin but did not hold the insulin pens in the resident's skin for the required duration to ensure the full dose was administered. This resulted in visible liquid streaming from the needle and the resident feeling something drip on her. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that staff should hold the insulin pen for several seconds after administration to ensure the full dose is delivered, but the LPN did not adhere to this protocol. The manufacturer's instructions for both Lantus and Humalog insulin pens specify that the needle should be held in the skin for a certain number of seconds after the dose is administered to ensure the full dose is delivered. The facility's policy for insulin administration also aligns with these instructions. However, the LPN did not follow these guidelines, leading to the medication error. Interviews with the ADON, DON, and Corporate Nurse confirmed the expected procedure, but the LPN's actions did not comply with these standards, resulting in a medication error rate above the acceptable threshold.
Improper Insulin Administration Leading to Medication Errors
Penalty
Summary
The facility failed to properly administer insulin to a resident with diabetes, leading to significant medication errors. During an observation, an LPN administered Glargine insulin and Humalog insulin to the resident but did not follow the manufacturer's instructions for proper administration. Specifically, the LPN did not hold the insulin pens in the resident's skin for the required amount of time to ensure the full dose was administered. This resulted in insulin leaking from the needle after removal, and the resident reported feeling something dripping on her. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed that staff should hold the insulin pen for several seconds after administration to ensure the full dose is delivered. The manufacturer's instructions for both Lantus and Humalog insulin pens specify that the needle should be held in the skin for a certain number of seconds after the dose is administered to ensure the full dose is delivered. The facility's policy for insulin administration also aligns with these instructions. However, the LPN did not adhere to these guidelines, leading to the medication error. Interviews with the ADON, DON, and a Corporate Nurse confirmed the proper procedure and highlighted the discrepancy in the LPN's actions. The facility's failure to follow proper insulin administration procedures resulted in a significant medication error for the resident.
Inaccurate MDS Assessment for Resident with Level II PASRR
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident diagnosed with non-Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder. The MDS assessment did not reflect the resident's Level II PASRR status, which indicated serious mental illness and/or intellectual disability. The resident's care plan, however, did acknowledge the Level II PASRR and associated diagnoses, including major depressive disorder, anxiety, bipolar disorder, traumatic brain injury, and dementia. Interviews with staff revealed that the PASRR was completed by the hospital prior to the resident's admission, and the facility's social worker was aware of the Level II PASRR status. The Assistant Director of Nursing, who completed the MDS assessments, admitted to using various sources of information but failed to update the MDS to reflect the accurate PASRR status. The facility also lacked a specific PASRR policy, as confirmed by the Administrator. The Behavioral Assessment, Intervention, and Monitoring policy indicated the use of the PASRR evaluation report for resident assessment and care plan development, but this was not followed in the MDS assessment for the resident in question.
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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