Valley Vista For Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Newton, Iowa.
- Location
- 200 South Eighth Avenue East, Newton, Iowa 50208
- CMS Provider Number
- 165427
- Inspections on file
- 34
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Valley Vista For Nursing And Rehabilitation during CMS and state inspections, most recent first.
Two residents were not protected from abuse when one cognitively impaired, non-ambulatory resident who preferred to stay in common areas was reportedly placed in his room with the door closed by a CNA to avoid his vocalizations, keeping him there for an extended period despite his gestures indicating he wanted to leave, as corroborated by his roommate and an RN. In a separate incident, a resident with dementia and mood disorders was observed by an RN being kissed twice on the mouth and held around the waist by a female visitor later identified as a facility cook, and later seen walking hand-in-hand with her, while the same staff member had also sought to take another resident out overnight and obtain that resident’s medications without guardian consent. The facility’s abuse policy defined abuse to include involuntary seclusion and exploitation but did not address how residents would be protected during investigations, and the described events demonstrate failures to prevent unreasonable confinement and potential sexual exploitation.
A resident with cerebral palsy, severe intellectual disability, and a strong preference for staying in the common area was allegedly placed in his room with the door closed by a CNA to avoid hearing his vocalizations, and left there for an extended period despite his gestures indicating he wanted out. Another CNA reported the incident to an RN, and the roommate confirmed that staff sometimes shut the door when the resident wanted to leave the room. Although facility policy defined abuse to include involuntary seclusion and required reporting allegations to the State Agency within 2 hours, the DON and Administrator stated they were not informed, and there was no documentation that the allegation was reported to the State Agency as required.
A resident with cerebral palsy, severe intellectual disability, and severe cognitive impairment, who depended on staff for most ADLs and preferred to stay in the common area, was allegedly placed in his room with the door closed by a CNA so the CNA would not have to hear his vocalizations, and kept there for an extended period despite his apparent wish to leave. Another CNA reported the incident to an RN, and the roommate confirmed that staff sometimes shut the door when the resident wanted out, but the RN only mentioned the concern to the DON in passing. The DON and Administrator stated such allegations should be reported directly to them and that the alleged perpetrator should be separated from residents, yet there was no documentation that an abuse investigation was initiated or that the CNA was separated from residents, despite an abuse policy that defined abuse to include involuntary seclusion and required timely reporting and investigation.
The facility did not update care plans for several residents to reflect current interventions, treatments, and preferences. Examples included outdated documentation of discontinued medications, lack of updates for wound care and nutrition interventions, and failure to note changes in code status, transfer needs, and hospice services. Staff interviews confirmed that care plans were not consistently revised as required by facility policy.
The facility failed to accurately complete MDS assessments for two residents, with one case involving unreported significant weight loss despite EHR documentation and another involving the omission of a serious mental illness diagnosis confirmed by PASRR. The MDS Coordinator acknowledged both errors, which were inconsistent with the 2024 RAI guidance.
A resident with end stage renal disease and diabetes did not consistently receive required pre and post dialysis assessments as ordered by the physician. Multiple dates were identified where these assessments were not documented, and facility leadership acknowledged the omissions. No policy was available to guide staff on the procedure for completing these assessments.
Two residents with complex medical needs did not have current nutrition progress notes or assessments readily accessible in the EHR, as required. The RD's documentation was inconsistently scanned or maintained on a personal jump drive, leading to gaps in the medical record and lack of timely access for staff.
Staff did not follow infection control protocols in two cases: an LPN administered an insulin injection to a resident without wearing gloves, and a medication aide assisted a resident on enhanced barrier precautions without wearing a required gown. Both staff members acknowledged the lapses, and the DON confirmed that facility policy requires proper PPE use during these procedures.
Two residents who enrolled in hospice care did not have Comprehensive MDS Assessments completed and transmitted within the federally required timeframe. In one case, the assessment was completed late, and in the other, it was not completed at all, as confirmed by staff review.
Several residents who required assistance with bathing did not consistently receive scheduled showers or bed baths, with some reporting missed care and dissatisfaction with the quality of hygiene provided. Audit records confirmed that on multiple days, most scheduled baths were not completed or documented, and care plans were not always updated to reflect residents' needs. Facility policy required support for ADLs, but inconsistent documentation and failure to follow procedures led to unmet hygiene needs.
The facility failed to provide adequate weekend staffing, resulting in delayed call light responses and unmet resident needs. Residents reported long wait times for assistance, with one waiting up to an hour and 45 minutes. Staff confirmed fewer CNAs on weekends, leading to incontinence and unmet needs. Grievance records showed complaints about long wait times, and audits were not conducted during weekends or nighttime. The administrator acknowledged staffing issues due to call-ins and no-shows.
Two residents reported incidents of disrespect and inadequate care. One resident was left on a bedpan for hours, causing discomfort, and felt uneasy with CNAs speaking in a foreign language during care. Another resident experienced delayed call light responses, leading to incontinence and embarrassment. The facility's dignity policy was not followed.
A facility failed to document a resident's code status by not having an Iowa Physician Orders for Scope of Treatment (IPOST) form or a physician's order for a Do Not Resuscitate (DNR) status. Despite the resident's documented DNR status in their care plan, the absence of the IPOST form and physician's order meant the resident would be treated as a full code in an emergency. The Director of Nursing expected all residents to have a completed IPOST form.
A resident with multiple wounds did not receive consistent wound care as prescribed, with treatments often undocumented or incomplete over several months. Interviews revealed staff inconsistencies in treatment application, and the DON admitted to lapses in documentation. Facility policies requiring immediate documentation were not followed, leading to a deficiency in wound care management.
The facility failed to assist two residents with shaving, as they were only shaved on shower days despite their requests for more frequent shaving. One resident, with Parkinson's and no cognitive impairment, reported the facility often lacked razors, affecting his grooming. Another resident, with moderate cognitive impairment, also expressed dissatisfaction with the infrequent shaving schedule. The facility's policy aimed to promote cleanliness and skin care, but the practice did not meet residents' needs.
A resident with a history of stroke and hemiplegia reported shoulder pain after a CNA moved him too quickly during care, causing his shoulder to hit the wall. Despite the resident's report, no assessment or medical evaluation was conducted. Staff involved did not report the incident to management, and the facility's pain management policy was not followed, leading to a deficiency in care.
A resident with mobility issues was pushed in a wheelchair without foot pedals by a CNA, contrary to facility policy. The resident was barefoot, with a wrap around her calves, exposing her toes. The CNA claimed management instructed not to use foot pedals due to skin issues, but the DON stated no such directive was given. The facility's policy requires foot pedals for safety during wheelchair transport.
A facility failed to maintain infection control standards by not using PPE during high-contact care for a resident on enhanced barrier precautions. An RN was observed without a gown or gloves while handling the resident's wound vac tubing and bed sheet, contrary to the facility's protocol requiring PPE for residents with wounds or medical devices. Interviews confirmed the expectation for PPE use, indicating a breach in procedure.
A resident with a history of congestive heart failure and other conditions was admitted to the hospital with pressure ulcers that were not accurately documented by the LTC facility. Despite previous documentation of skin issues, daily skilled assessments failed to note these concerns. Staff interviews revealed inconsistencies in skin assessments and communication with physicians, leading to a deficiency in pressure ulcer care.
The facility failed to prevent the deterioration of pressure ulcers in two residents. One resident, admitted with a Stage 2 ulcer, experienced worsening conditions due to inadequate documentation and implementation of care plans, including the use of an air mattress and regular repositioning. Another resident, with Stage 3 ulcers, was not repositioned as needed, and the clinical record lacked detailed wound documentation. The facility's DON confirmed the lack of necessary documentation and adherence to care plans.
The facility failed to complete prescribed treatments for two residents, leading to deficiencies in care. One resident with a stage 2 pressure ulcer did not receive several wound care treatments and medications as ordered. Another resident with pressure ulcers also missed multiple wound care treatments. The facility's DON confirmed that treatments were expected to be completed as per the MAR and TAR instructions, but the lack of documentation indicated they were not performed.
A resident with a history of aggressive behavior was involved in multiple altercations with other residents, resulting in injuries. Despite having a care plan, the resident's behavior was not adequately managed, leading to a deficiency in supervision and safety. Facility staff acknowledged the need for increased supervision to prevent further incidents.
The facility failed to maintain proper infection control practices when animal feces was observed on a couch in the rehab dining room, an area accessible to residents and used for conferences. The Regional Director of Operations and the Administrator acknowledged the issue, citing past problems with dogs and the possibility of the facility's cats being responsible. The facility's policy mandates environmental cleaning and disinfection.
A resident was taken to an outside appointment wearing only a shirt and briefs, with a blanket wrapped around her, leading to feelings of embarrassment and a violation of her dignity. Staff failed to ensure she was appropriately dressed, and the facility's policy on maintaining resident dignity was not followed.
The facility failed to meet professional standards in medication administration and following physician orders for three residents. Eye drops for one resident were administered outside the scheduled time frames, ACE bandages were not applied daily for another resident, and a laxative mixture was left unattended with a third resident. The Director of Nursing and Administrator acknowledged these deficiencies.
The facility failed to ensure that residents received at least two baths or showers per week. Three residents, including those with conditions such as morbid obesity, cellulitis, hemiplegia, stroke, arthritis, and non-Alzheimer's dementia, did not have adequate documentation of showers or baths being provided or offered. The facility's policy on maintaining proper hygiene was not consistently followed.
Failure to Prevent Unreasonable Confinement and Sexual Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including unreasonable confinement and sexual exploitation, as required by its abuse policy. For one resident with cerebral palsy, severe intellectual disability, a BIMS score of 1/15, and dependence on staff for mobility and ADLs, staff and resident interviews indicated that a CNA placed the resident in his room and closed the door so she would not have to hear his vocalizations. The resident was described in the care plan and by staff as preferring to be in the common area near the nurses’ station, watching people and making his needs known through gestures and vocalizations. A CNA reported that on a specific day she observed another CNA put the resident in his room and close the door, and that the resident remained in the room for 45 minutes to an hour despite his preference to be out of the room. The resident’s cognitively intact roommate corroborated that staff sometimes shut the door when the resident wanted out of the room, and confirmed that the resident liked to be in the common area. The RN familiar with the resident stated that he did not like to be in his room and that staff understood his wishes through his grunting and pointing. She acknowledged that another CNA had reported to her that a CNA placed the resident in his room and closed the door, and that the roommate had activated the call light, after which the CNA entered, the resident pointed toward the door indicating he wanted out, and the CNA told him she would be back in a minute and then closed the door. The RN stated she relayed this information to the DON “in passing,” but there was no indication that this allegation was formally reported or investigated at the time. The deficiency also includes an incident of alleged sexual exploitation involving another resident with non-Alzheimer’s dementia, anxiety, depression, and a BIMS score of 8/15. A staff RN reported that she entered the resident’s room to administer medication and observed a female visitor with a child present kiss the resident twice on the mouth while holding him around the waist, and later saw them walking down the hall holding hands. The RN later learned the visitor was a facility cook who knew the resident prior to admission and had also requested to take another resident out overnight and obtain that resident’s medications without guardian permission. The facility’s abuse policy defined abuse to include involuntary seclusion and exploitation and required timely reporting and investigation, but did not specify how residents would be protected during an investigation, and the events described show that residents were subjected to alleged unreasonable confinement and potentially exploitative physical contact by a staff member/visitor.
Failure to Report Allegation of Involuntary Seclusion to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse, specifically involuntary seclusion, to the State Agency for one resident. Resident #7 had cerebral palsy, severe intellectual disabilities, a history of healed traumatic fractures, was dependent on staff for most activities of daily living, and had a BIMS score of 1/15 indicating severely impaired cognition. Care plan entries documented that the resident liked to spend time in the common area watching TV, listening to music, and people watching, and that he could express basic needs through body language and simple verbalizations. The facility’s Abuse Policy defined abuse to include involuntary seclusion and required reporting to the State Agency within 2 hours, along with a timely and thorough investigation. On a day when Staff A CNA was documented as providing care to the resident, Staff E CNA reported that the resident was making vocalizations and that Staff A placed him in his room and closed the door so she would not have to hear him, leaving him there for 45 minutes to an hour despite his preference to be in the common area. Staff E stated she reported this to Staff F RN, and the resident’s roommate confirmed that staff sometimes shut the door when the resident wanted out of the room. Staff F initially denied knowledge of such actions but then acknowledged that Staff E had reported that Staff A placed the resident in his room and closed the door, and that the roommate had activated the call light. The DON and Administrator both stated that such an incident should have been reported as an allegation of abuse and investigated, but neither had received a report of this allegation. The facility lacked documentation that the allegation was reported to the State Agency prior to 2/25/26, contrary to its abuse reporting policy.
Failure to Investigate Alleged Involuntary Seclusion and Protect Resident During Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of abuse and to ensure resident safety during the investigation for one resident with severe cognitive impairment. Resident #7 had cerebral palsy, severe intellectual disabilities, a history of healed traumatic fractures, was dependent on staff for most ADLs, and did not ambulate. The resident’s MDS and care plan documented that he preferred to spend time in the common area watching TV, listening to music, and people watching, and that he communicated basic needs through body language and limited verbalizations. On a February day shift, Staff A CNA was documented as providing multiple ADL cares to the resident. Staff E CNA later reported that on a Saturday, Resident #7 was making vocalizations and Staff A placed him in his room and closed the door so she would not have to hear him, keeping him there for 45 minutes to an hour despite his preference to be out of the room. Staff E stated she reported this to Staff F RN, and that the resident’s roommate was present at the time. Resident #8, the roommate, stated that at times Resident #7 wanted out of the room and staff shut the door, and confirmed that Resident #7 liked to be in the common area. Staff F RN acknowledged that Resident #7 did not like to be in his room and communicated his wishes by grunting and pointing, and, after further questioning, confirmed that Staff E had reported to her that Staff A placed the resident in his room and closed the door, with the roommate activating the call light. Staff F believed the incident occurred a couple of weeks before it was reported to her and stated she only mentioned it to the DON “in passing.” Staff A denied closing the door against the resident’s wishes and stated she could interpret some of his gestures, and did not think she had cared for him that weekend. The DON and Administrator both stated that such an allegation should be reported to them, that residents should be free from abuse, and that they would have separated the alleged perpetrator from residents and reported and investigated the allegation. The facility’s abuse policy defined abuse to include involuntary seclusion and required timely reporting and thorough investigation, but did not specify how to protect residents during an investigation. The facility lacked documentation that any investigation was carried out or that residents were separated from Staff A prior to February 25.
Failure to Timely Update Resident Care Plans to Reflect Current Conditions and Interventions
Penalty
Summary
The facility failed to update and revise resident care plans in a timely manner to reflect current conditions and interventions for five residents. For one resident with diabetes and end stage renal disease, the care plan continued to list a discontinued topical numbing cream, despite documentation in the progress notes and treatment administration record that the intervention had been stopped due to patient complaints. The MDS Coordinator acknowledged that the care plan did not reflect the current medicated cream in use. Another resident with multiple diagnoses, including diabetes, heart failure, and a colostomy, had a care plan that listed negative pressure wound therapy (NPWT) and a weight goal that did not match the resident's current weight trend. The NPWT had been discontinued, and the registered dietitian acknowledged that the nutrition care plan had not been updated to reflect the resident's actual weight. Similarly, a resident with severe cognitive impairment and multiple comorbidities had a care plan that did not include a physician-ordered protein supplement for wound healing, nor did it reflect the resident's current weight trend, despite documentation in the electronic health record. Additional deficiencies included a resident with a stage 3 pressure ulcer whose care plan did not reflect her refusal to use a chair cushion or alternative interventions, and another resident whose care plan did not accurately reflect her current code status, transfer needs, or hospice services. Staff interviews confirmed that care plans were not consistently updated to reflect changes in health status, interventions, or resident preferences, despite facility policy requiring ongoing assessment and timely revision of care plans.
Inaccurate MDS Assessments for Weight Loss and Mental Illness Diagnosis
Penalty
Summary
The facility failed to submit accurate information on the Comprehensive Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS assessment did not accurately reflect a significant weight loss of 10% or more over the previous six months, as documented in the electronic health record (EHR). The MDS recorded the resident's weight and indicated no significant weight loss, despite EHR documentation showing a decrease from 272 pounds to 235 pounds over the relevant period. The MDS Coordinator acknowledged that the weight loss section was incorrectly answered and that the resident was on a physician-prescribed weight loss regimen. For another resident, the MDS assessment failed to accurately report the presence of a serious mental illness as determined by the PASRR Level II screening. Although the EHR and PASRR documentation confirmed a diagnosis of bipolar disorder, the MDS incorrectly indicated that the resident did not have a serious mental illness. The MDS Coordinator confirmed that the relevant section of the MDS was answered incorrectly, contrary to the guidance provided in the 2024 Resident Assessment Instrument (RAI).
Failure to Complete Pre and Post Dialysis Assessments
Penalty
Summary
The facility failed to consistently complete required pre and post dialysis assessments for a resident with end stage renal disease and diabetes, as directed by current physician orders. Review of the electronic health record and monthly Treatment Administration Records revealed multiple dates where no pre and post dialysis assessments were documented, including several specific days across April, May, July, and August. During interviews, the resident was unable to recall if staff obtained vital signs before dialysis, though believed blood pressures were taken upon return. The Administrator and DON acknowledged the lack of dialysis assessments on the identified dates. Additionally, the facility was unable to provide a policy outlining the procedure for completing pre and post dialysis assessments.
Incomplete and Inaccessible Nutrition Documentation in Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for two residents reviewed for nutrition. For one resident with diabetes and end stage renal disease, the electronic health record (EHR) lacked nutrition documentation for over nine months, with the last dietary assessment dated several months prior to the most recent care plan revision. The care plan required quarterly registered dietitian (RD) consultations and monitoring for malnutrition, but the required documentation was not present in the EHR. For another resident with severe cognitive impairment, Alzheimer's disease, and other comorbidities, the EHR similarly lacked current nutrition documentation, with the last nutrition risk assessment completed several months before the most recent care plan update. This resident's care plan included interventions for a mechanically altered diet and history of weight loss, but the supporting RD documentation was missing from the EHR. Interviews with the DON revealed uncertainty about the RD's charting process and an inability to locate current RD documentation in the EHR. The DON later found that some RD progress notes had been scanned into the EHR, but this process was not consistent or timely. The RD confirmed that nutrition-related entries were kept on a personal jump drive and that the process of printing and sending notes to the facility had not been routinely completed for an unknown period. As a result, staff did not have timely access to up-to-date nutrition assessments and progress notes for these residents.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to adhere to infection control standards in two separate incidents. In the first instance, a Licensed Practical Nurse administered an insulin injection to a resident without wearing gloves. The nurse later acknowledged the omission and confirmed awareness of the requirement to use gloves during such procedures. The Director of Nursing also stated that staff are expected to always wear gloves when administering insulin injections, as outlined in the facility's policy on glove use during invasive procedures. In the second incident, a Certified Medication Aide entered the room of a resident on enhanced barrier precautions, wearing only gloves and not a gown, and provided hands-on assistance by repositioning the resident. The aide admitted that a gown should have been worn in addition to gloves for this type of care, as the resident required both due to being on enhanced barrier precautions. The Director of Nursing confirmed that the expectation is for staff to use both gown and gloves for hands-on care with residents on enhanced barrier precautions, in accordance with facility policy.
Failure to Complete Timely MDS Assessments After Hospice Admission
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments following a significant change in condition for two residents who were admitted to hospice care. For one resident, the electronic health record documented hospice enrollment, but the Significant Change MDS assessment was not completed within the required timeframe, as the assessment was finalized 20 days after hospice admission. For the second resident, there was no evidence that a Significant Change MDS assessment was completed at all following hospice enrollment, as verified by the MDS Coordinator during a review of the resident's records. According to the 2024 Resident Assessment Instrument (RAI) Manual and the facility's own policy, a comprehensive assessment is required within 14 days of a significant change in a resident's status, such as enrollment in hospice care. The failure to complete and transmit these assessments as required was identified through clinical record review, staff interview, and policy review, and involved two residents out of a census of 54.
Failure to Provide Consistent Bathing and ADL Assistance
Penalty
Summary
The facility failed to provide consistent bathing and assistance with activities of daily living (ADLs) for several residents over a four-day period. Clinical record reviews and resident interviews revealed that multiple residents who required substantial or maximal assistance with bathing did not consistently receive scheduled showers or bed baths. One resident, who was cognitively intact and required two staff for bathing, reported missing multiple showers over a two-month period, resulting in feelings of being unclean. Another resident with moderate cognitive impairment primarily performed sink baths independently, expressing dissatisfaction with the quality of staff-assisted showers and noting that staff often did not wash his hair or ensure he was clean. A third resident, bedbound after a medical procedure, reported not always receiving scheduled bed baths and sometimes refused care when staff attempted to use wet wipes instead of soap and water, preferring to wait for staff who would provide care according to her preferences. Audit sheets for the month indicated significant lapses in the completion of scheduled baths and showers. On several days, the majority of residents scheduled for bathing did not receive their baths, and there was no documentation of make-up baths on subsequent days. In one instance, a single staff member was assigned an unusually high number of baths in one shift and documented that all assigned residents refused, with no evidence that the required protocol for repeated offers and nurse notification was followed. The Assistant Director of Nursing confirmed the accuracy of the audit sheets and acknowledged the lack of records for completed baths on the specified days. Facility policy required that residents unable to perform ADLs independently receive necessary services to maintain hygiene, including regular bathing, in accordance with their care plans. However, care plans were not always updated to reflect current bathing needs, and documentation practices were inconsistent. The failure to provide scheduled bathing and to follow established procedures for refusals and documentation resulted in unmet hygiene needs for several residents.
Inadequate Weekend Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate staffing on weekends, leading to delayed responses to call lights and unmet resident needs. Interviews with residents and staff revealed that the facility had fewer staff on weekends, resulting in longer wait times for call light responses. Residents reported waiting over 15 minutes, and in one case, up to an hour and 45 minutes for assistance. Staff confirmed that the facility operated with at least one less Certified Nurse Aide (CNA) on weekends, and management or office staff who typically assisted during the week were not available on weekends. This staffing shortage led to residents experiencing incontinence and unmet needs due to delayed assistance. The facility's grievance records showed complaints about long wait times for call light responses, particularly on weekends. One resident reported waiting 30-45 minutes for assistance and had to wheel themselves to the nurse's station without oxygen. The facility's call light audits were conducted during daytime hours on weekdays, not addressing the weekend or nighttime issues. The administrator acknowledged the staffing issues, citing frequent call-ins and no-shows as contributing factors. Despite having more staff hired and rotating them on weekends, the facility continued to receive complaints about call light response times.
Failure to Ensure Resident Dignity and Timely Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by incidents involving two residents. Resident #13, who has intact cognition and requires assistance with activities of daily living due to a stroke and hemiplegia, reported being left on a bedpan for 3-4 hours, causing discomfort and pain. The resident also expressed distress over two CNAs speaking in a language he did not understand while providing care, which made him feel uncomfortable and rushed. Despite reporting these issues to the Administrator, the resident felt that the situation was not adequately addressed, as the Administrator did not recall being informed about the prolonged use of the bedpan. Resident #40, who has moderate cognitive impairment, reported that staff did not respond to call lights in a timely manner, resulting in incontinence and feelings of embarrassment and shame. The facility's policy on Quality of Life-Dignity, which emphasizes the importance of treating residents with dignity and respect, was not adhered to in these instances. The Director of Nursing acknowledged the expectation for timely response to call lights to assist residents with toileting, highlighting a failure in meeting this standard.
Failure to Document Resident's Code Status
Penalty
Summary
The facility failed to have an Iowa Physician Orders for Scope of Treatment (IPOST) form for one of the residents, which is a medical order form that records residents' treatment wishes in the event of a medical emergency. The resident in question had a documented Code Status of Do Not Resuscitate (DNR) in their Admission Narrative Bundle/Baseline Care Plan. However, upon review, the facility's IPOST book and the resident's electronic record lacked the IPOST form and a physician's order for the code status. A registered nurse confirmed that in the absence of an IPOST form or physician's order, the resident would be treated as a full code, meaning cardiopulmonary resuscitation would be performed. The Director of Nursing stated that there was an expectation for all residents to have a completed IPOST form in the IPOST book.
Inconsistent Wound Care Documentation and Treatment
Penalty
Summary
The facility failed to adhere to professional standards of nursing care, specifically in the area of wound care for one resident. The resident, who had intact cognition and was at risk for pressure ulcers, had multiple wounds including a stage 3 pressure ulcer and moisture-associated skin damage. The care plan required specific treatments and dressings to be applied as prescribed by the wound care ARNP, but these were not consistently documented or completed over several months. Interviews with the resident revealed inconsistencies in the treatment application, with staff not always following the prescribed method. The Treatment Administration Record (TAR) showed numerous instances where treatments were not recorded as completed, spanning from June to September. The Director of Nursing (DON) acknowledged that some treatments might not have been completed and admitted to forgetting to document treatments in the TAR. The facility's policy required immediate documentation of services provided, which was not adhered to in this case. The Administrator and DON both stated expectations for staff to document treatments immediately after completion and to follow prescribed orders. However, the review of the facility's policies and interviews indicated a failure to meet these expectations, leading to the deficiency in wound care management for the resident.
Failure to Assist Residents with Shaving
Penalty
Summary
The facility failed to assist residents with shaving, as observed in two residents. Resident #27, diagnosed with Parkinson's disease and muscle weakness, had no cognitive impairment and expressed a desire to be shaved more frequently than the current schedule of twice a week on shower days. The resident reported that the facility was often out of razors, and on one occasion, did not receive a scheduled shower or shave. Documentation on the resident's shower sheet confirmed the lack of razors as a reason for not shaving. Resident #40, with a diagnosis of Non-Alzheimer's Disease and moderate cognitive impairment, also expressed dissatisfaction with the frequency of shaving, which was limited to shower days. Observations over several days showed the resident with facial hair and confirmed that shaving had not occurred as desired. The facility's policy, revised in February 2018, stated that shaving should promote cleanliness and skin care, but the Director of Nursing indicated that shaving was expected on shower days and more frequently if requested by residents.
Failure to Assess and Address Resident's Shoulder Pain
Penalty
Summary
The facility failed to accurately assess and provide intervention for a resident who reported shoulder pain. Resident #13, who had a history of stroke and hemiplegia, required substantial assistance with activities of daily living. The resident reported that a CNA, Staff D, moved him too quickly during care, causing his shoulder to hit the wall and resulting in pain. Despite the resident's report of pain and the incident, no assessment or medical evaluation was conducted on the resident's shoulder. Interviews with staff revealed inconsistencies in the handling of the incident. Staff D admitted to moving the resident by his sore shoulder but denied slamming him into the wall. Staff E, a CMA, was informed by the resident about the incident but did not recall specific details about the resident's pain or whether Tylenol was administered. Neither Staff D nor Staff E reported the incident to the charge nurse or management, and there was no documentation of an assessment in the resident's electronic health record. The facility's Administrator was unaware of the incident until the survey. The facility's policy on pain management and assessment, which requires a multidisciplinary approach to alleviate pain, was not followed. The lack of communication and failure to assess the resident's shoulder pain led to a deficiency in providing appropriate care according to the resident's needs and preferences.
Failure to Ensure Safe Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe transport of a resident in a wheelchair, leading to a deficiency in accident prevention and supervision. The resident, who had orthopedic conditions and mobility issues, was observed being pushed in a wheelchair without foot pedals by a CNA. The resident was barefoot, with a wrap around her calves, leaving her toes exposed. This occurred despite the facility's policy requiring the use of foot pedals for safety during wheelchair transport. The CNA reported being instructed by management not to use foot pedals for this resident due to skin issues on her legs, although the Director of Nursing (DON) stated that no such directive was given by current management. The DON confirmed the expectation that foot pedals should be used for safety when pushing residents in wheelchairs. The facility's policy emphasizes maintaining an environment free of accident hazards and providing adequate supervision and assistive devices to prevent accidents.
Infection Control Breach in Resident Care
Penalty
Summary
The facility failed to adhere to infection control standards by not using personal protective equipment (PPE) during high-contact care activities for a resident on enhanced barrier precautions (EBP). The resident, who had a surgical wound and a Foley catheter, was observed in their room with a sign indicating EBP and PPE supplies available outside the door. Despite this, a registered nurse (RN) was seen in the resident's room without wearing a gown or gloves. The RN lifted the resident's bed sheet and touched the wound vac tubing without performing hand hygiene, subsequently touching her own clothing. Interviews with staff revealed that the protocol for residents on EBP requires wearing a gown, gloves, and mask during direct care activities, especially when handling wounds, bedding, or medical devices. The facility's policy, revised earlier in the year, mandates the use of EBP for residents with wounds or indwelling medical devices during high-contact care activities. The Director of Nursing confirmed the expectation for staff to wear PPE when in contact with the resident or their environment, highlighting a clear deviation from established procedures in this instance.
Deficiency in Pressure Ulcer Documentation and Care
Penalty
Summary
The facility failed to accurately document and assess pressure ulcers for a resident, leading to a deficiency in pressure ulcer care. The resident, who had a medical history of congestive heart failure, generalized weakness, osteoporosis, and hypertension, was admitted to the hospital with a decubitus ulcer on the buttocks. The facility's records showed inconsistencies in documenting the resident's skin condition, with daily skilled charting indicating no open areas or skin issues, despite previous documentation of skin concerns. Interviews with staff revealed a lack of consistent skin assessments and documentation. A registered nurse reported conducting weekly skin assessments and noted open skin areas on the resident's lower legs, but not on the heels. However, daily skilled assessments failed to document these issues. A CNA reported notifying a nurse about the resident's red and potentially opening skin on the buttocks, but this was not reflected in the skilled assessments. The Assistant Director of Nursing and the Director of Nursing both acknowledged that skin concerns should be documented and communicated to physicians, but this was not consistently done. The facility's policy on wound documentation required thorough assessment and documentation of pressure injuries, but this was not adhered to in the case of the resident. The hospital's progress notes indicated the resident had stage 2 decubitus ulcers on the buttocks and unstageable wounds on the lower legs and heels, which were not properly documented or addressed by the facility. This lack of accurate documentation and follow-up contributed to the deficiency in pressure ulcer care for the resident.
Failure to Prevent Deterioration of Pressure Ulcers
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to prevent pressure ulcers from deteriorating for two residents. Resident #1, who had a history of pressure ulcers, was admitted with a Stage 2 pressure ulcer on the coccyx. Despite having a care plan that included interventions such as using an air mattress and turning the resident side to side, the clinical record lacked documentation of weekly skin measurements and the application of the air mattress upon admission. The resident's condition worsened, with the development of a Stage 2 pressure ulcer on the left buttock, indicating a lack of effective pressure ulcer management. Resident #8, who returned from an acute care hospital with a diagnosis of pressure ulcers, was documented to have two Stage 3 pressure ulcers on the sacral and buttock regions. The resident's care plan included a pressure-reducing device and a turning schedule, but there was no documentation of a strict turning schedule being implemented. Observations revealed that the resident was not repositioned as frequently as needed, and the clinical record lacked detailed documentation of the wound's size and description, which is crucial for monitoring and treatment. The facility's Director of Nursing confirmed that the clinical records for both residents lacked necessary documentation, such as weekly skin measurements and adherence to a strict turning schedule. The facility's policy required accurate documentation of wound assessments and treatments, including changes in condition and response to treatment, which was not consistently followed. This lack of documentation and adherence to care plans contributed to the deterioration of pressure ulcers in both residents.
Failure to Complete Prescribed Treatments for Residents
Penalty
Summary
The facility failed to adhere to professional standards of nursing care by not completing prescribed treatments and dressings for two residents. Resident #1, who had a stage 2 pressure ulcer and other medical conditions such as anemia and malnutrition, did not receive several treatments as ordered. The Medication Administration Record (MAR) and Treatment Record (TAR) indicated multiple instances where treatments were not completed, including the application of wound dressings and administration of medications. These omissions occurred over several months, despite clear instructions on the MAR and TAR. Resident #8, diagnosed with conditions including anemia, hypertension, and pressure ulcers, also experienced lapses in care. The MAR and TAR documented that wound care treatments were not completed on several occasions. These treatments were crucial for the resident's wound healing process, yet they were missed repeatedly over two months. The facility's Director of Nursing and Assistant Director of Nursing confirmed that the treatments were expected to be completed as per the MAR and TAR instructions. The facility's policy on wound treatment documentation required that treatments be documented at the time of completion. However, the failure to check the boxes on the MAR and TAR indicated that the treatments were not performed. This lack of adherence to the facility's policy and the prescribed treatment plans contributed to the deficiency identified by the surveyors.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision to ensure the safety of residents from a particular resident who had verbal and physical altercations with others. Resident #4, who has a history of hypertension, insomnia, and depression, was involved in incidents on multiple occasions, including a physical altercation with Resident #3. Despite having a care plan in place that included interventions such as one-on-one supervision and behavior monitoring, Resident #4 continued to exhibit aggressive behavior. On one occasion, Resident #4 became agitated when attempting to access the bathroom, leading to a physical altercation with Resident #3. The incident resulted in Resident #3 sustaining injuries, including abrasions and bruising. The facility's progress notes and incident reports documented Resident #4's ongoing agitation and inability to be redirected, highlighting the need for increased supervision and intervention to prevent further incidents. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that Resident #4 required increased supervision due to previous altercations and threats of aggression. The facility's failure to adequately supervise and manage Resident #4's behavior resulted in a deficiency in ensuring a safe environment for all residents, as outlined in the facility's Resident Rights Policy.
Infection Control Lapse Due to Animal Feces in Resident Area
Penalty
Summary
The facility failed to maintain proper infection control practices when animal feces was observed on a couch in the rehab dining room. This area is accessible to residents and is also used as a conference room and by families. The Regional Director of Operations acknowledged the feces and mentioned past issues with people bringing in dogs and not cleaning up after them. The Administrator suggested the feces could have been from one of the facility's two cats. The facility's Infection Prevention and Control Program policy, dated 12/1/23, mandates environmental cleaning and disinfection, and requires all staff to report cleanliness issues outside their scope to the appropriate department.
Resident Taken to Appointment Without Proper Clothing
Penalty
Summary
The facility failed to promote resident dignity when a resident was taken to an outside appointment wearing only a shirt and briefs, with a blanket wrapped around her. The resident, who had intact cognition and required assistance with dressing due to conditions such as a stroke and hemiplegia, reported feeling naked and embarrassed upon arrival at the appointment. The resident stated that she normally goes to appointments fully dressed and had appropriate clothing in her drawers at the facility. Staff interviews revealed that the resident was bundled in a blanket, and the driver did not check if she was dressed appropriately. Additionally, a CNA mentioned that the resident did not have any pants that fit her at the time, and another staff member confirmed that it was not unusual for the resident to wear a t-shirt above her brief without pants. Upon arrival at the doctor's office, the resident's brief was found to be open and not taped closed, prompting the clinic staff to provide her with surgical pants. The facility's policy on promoting and maintaining resident dignity directs staff to groom and dress residents according to their preferences and maintain their privacy. The Director of Nursing stated that if a resident did not have proper clothing for an outside appointment, staff should follow up with the charge nurse or the DON for direction. The facility's failure to ensure the resident was appropriately dressed for her appointment resulted in a violation of her dignity and self-respect.
Medication Administration and Physician Orders Not Followed
Penalty
Summary
The facility failed to provide services that met professional standards regarding medication administration and following physician orders for three residents. For Resident #3, who had diagnoses including heart failure, renal insufficiency, diabetes mellitus, and lymphedema, eye drops were administered outside the scheduled time frames on multiple occasions. The Medication Administration Record (MAR) showed that the eye drops were given either too early or too late, contrary to the facility's policy and physician orders. The Director of Nursing acknowledged that medications should not be administered outside the prescribed time frames without physician notification and permission. Resident #6, who had diagnoses including diabetes mellitus and schizophrenia, required ACE bandages to be applied daily to her lower extremities for edema. However, the Treatment Administration Record (TAR) lacked documentation of the ACE bandages being applied on several dates in February and March 2024. During an observation, the resident confirmed that the wraps were not applied as ordered, and the Director of Nursing confirmed that treatments should be completed as per physician orders. For Resident #17, who had diagnoses including stroke, hemiplegia, and aphasia, a Certified Medication Assistant (CMA) left a mixture of PEG 3350 (a laxative) with the resident unsupervised. The resident had an order for the laxative to be administered twice daily. The CMA acknowledged leaving the medication unattended, and the Administrator confirmed that medications should not be left in a resident's room without a physician's order for self-administration. The facility's policy on medication administration requires that medications be administered as ordered by the physician and in accordance with professional standards.
Failure to Provide Required Baths/Showers
Penalty
Summary
The facility failed to ensure that residents received at least two baths or showers per week, as required. This deficiency was identified for three residents. Resident #14, who had diagnoses including morbid obesity and cellulitis of the groin, required staff assistance for bathing. The electronic health record (EHR) for Resident #14 lacked documentation of showers or baths being provided or offered in the past 30 days, and the Director of Nursing (DON) could only verify three instances of showers or refusals in March 2024. The DON acknowledged that Resident #14's showers were not scheduled in the EHR. Resident #17, who had diagnoses including hemiplegia and stroke, also required staff assistance for bathing. The EHR for Resident #17 showed that the resident had only five showers between February 19, 2024, and March 19, 2024, with no documentation of additional showers being offered. Similarly, Resident #18, who had diagnoses including arthritis and non-Alzheimer's dementia, required extensive assistance for bathing. The EHR for Resident #18 revealed that the resident had only four showers in the same 30-day period, with no documentation of additional showers being offered. The facility's policy stated that residents should be assisted with bathing to maintain proper hygiene, but this was not consistently followed for these residents.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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