Aspire Of Lake Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Park, Iowa.
- Location
- 1304 South Market, Lake Park, Iowa 51347
- CMS Provider Number
- 165445
- Inspections on file
- 16
- Latest survey
- September 24, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aspire Of Lake Park during CMS and state inspections, most recent first.
The facility failed to protect residents from verbal and mental abuse by two staff members, who yelled at residents, delayed responding to call lights, and refused assistance with toileting, leading to incontinence. Despite residents reporting these issues, the mistreatment continued, and the administration claimed to be unaware of the problems.
The facility failed to report and address allegations of abuse involving two CNAs, Staff B and Staff C, who were accused of verbally abusing residents, delaying response to call lights, and denying bathroom access. Despite multiple complaints from residents and staff, the administration and DON claimed to be unaware of these issues, and the facility did not report the allegations to the state agency as required.
The facility failed to investigate allegations of verbal and mental abuse by two staff members, leading to a deficiency. Multiple residents reported being yelled at and neglected by these staff, but the administration did not conduct an investigation or implement protective measures. Despite consistent complaints from residents and staff, the Director of Nursing and the Administrator claimed to be unaware of any issues, and no formal investigation was initiated.
The facility failed to provide appropriate mechanical soft diets to residents, serving BBQ shredded pork and pineapple chunks instead of the prescribed ground meat and thawed strawberries. Staff interviews revealed non-compliance with dietary guidelines, posing a choking hazard for residents with cognitive impairments. The facility's policies on therapeutic diets were not followed, leading to an immediate jeopardy situation.
A resident with severe cognitive impairment and a history of a Stage 4 pressure sore was found with an open wound on the left buttock, which was not promptly assessed or treated by the facility staff. Despite reports from CNA staff, the nursing team delayed notifying the physician and implementing treatment orders. Observations revealed the wound remained open and untreated, leading to an Immediate Jeopardy situation identified by the State Agency.
The facility failed to provide a resident-centered activity program, as evidenced by outdated activity calendars and a lack of structured activities. The Activities Director, new to the position, was unaware of prior activities, and the Administrator confirmed no documentation of activities for the past six months. A resident expressed boredom due to the lack of activities, highlighting the facility's non-compliance with its own policy on enhancing residents' well-being.
A facility failed to provide adequate nursing staff, resulting in significant delays in responding to call lights, administering medications, and serving meals. Residents experienced prolonged wait times for assistance, leading to incontinence episodes and distress. Staff interviews revealed systemic staffing challenges, with insufficient CNAs and nurses to meet resident needs, causing delays in care delivery.
The facility failed to manage resources effectively, leading to multiple Immediate Jeopardy deficiencies. Residents experienced mental and verbal abuse, with staff failing to report or investigate allegations. A resident's pressure sore was not properly treated, and dietary staff were unqualified, serving incorrect food textures. Inadequate staffing and communication tools further compromised care, with unreliable internet and fax capabilities hindering operations. The administrator struggled to manage two facilities, exacerbating staffing issues.
The facility did not secure medical records of current and former residents, as observed in an open storage room in the basement with direct outside access. Boxes containing records were on the floor, some appearing wet. Staff confirmed the lack of security and absence of a policy for protecting confidential records.
The facility failed to maintain a safe and clean environment, as water was found in the basement and mold-like substances were observed on various items in the storage area. Staff confirmed that these items had been wet and not cleaned up, contrary to facility policy.
The facility failed to provide residents with timely access to their funds, as required by policy. Three residents, all with no cognitive impairment, reported difficulties in accessing their money, with delays and restrictions noted, especially on weekends. Staff interviews revealed that the facility maintained a small amount of money with nurses, which was insufficient to meet residents' requests consistently.
The facility failed to follow physician's orders for two residents. One resident with chronic kidney disease was not weighed regularly, and Lasix was not administered despite significant weight gain. Another resident requiring tube feeding was not flushed with the prescribed amount of water before and after feeding. The DON confirmed the discrepancies in both cases.
The facility failed to provide baths to residents as per their desired frequency due to staffing shortages, affecting multiple residents. A resident with intact cognition reported not receiving baths twice a week, and observations confirmed greasy hair. Another resident with moderate cognitive impairment was observed with greasy hair and dirt under fingernails. A resident with no cognitive impairment required assistance with bathing but had only 3 baths documented in the past 30 days. A resident with severe cognitive impairment depended on staff for bathing and had only 1 bath in the previous 14 days. The facility's policy required at least two baths per week, but this standard was not met.
The facility failed to employ a Dietary Manager, leading to insufficient staffing and inadequate training in the food and nutrition service department. A Licensed Nursing Home Administrator from a sister facility was brought in to cook due to a lack of available staff, and the Housekeeping and Laundry Supervisor, with no formal kitchen training, was also called in to cook. The facility had only two dietary staff, one of whom worked only on Wednesday evenings due to another job.
The facility staff did not follow the planned menu for residents, which is essential for meeting their nutritional needs. The planned menu included BBQ pork, baked beans, glazed carrots, cornbread, margarine, and spiced peaches. However, the meal served consisted of BBQ pork on a bun, a dinner roll with margarine, carrots, and peaches, deviating from the planned menu. The Administrator confirmed that the only approved change was substituting cornbread with a dinner roll, indicating a failure to adhere to the set menu.
The facility did not serve meals at regular times as per resident needs and preferences. Observations showed delays in lunch service on two occasions, with meals served well past the scheduled noon time. A CDM confirmed that lunch should be served at noon, aligning with facility policy.
The facility failed to maintain sanitary conditions for food storage and preparation. Observations revealed improper temperature control in refrigerators and freezers, with food items lacking open dates and being stored at unsafe temperatures. Staff L, the LNHA working as the cook, did not verify temperatures, leading to the disposal of all items in affected units. Additionally, Staff U was seen in the kitchen without a hair net, and a food delivery was left outside in the sun. The Dietary Manager struggled to manage responsibilities across multiple buildings.
The facility exhibited several infection control deficiencies, including improper hand hygiene, lack of PPE use, and expired COVID-19 tests. Staff failed to follow enhanced barrier precautions during resident care, such as wound treatment and catheter management, and used expired COVID-19 tests for symptomatic residents and staff. These actions compromised infection prevention efforts.
The facility failed to maintain mechanical lifts in good working order, with a missing up button on the hand control and poor battery charging, as reported by CNAs. Despite these issues being reported to the Maintenance Director, no action was taken. The Administrator was unaware of the problems, and the facility lacked a policy on equipment repair.
A facility failed to conduct a care conference for a resident with intact cognition and multiple diagnoses, including hypertension and diabetes. The resident did not recall attending or being invited to a care conference, and the EHR lacked documentation of such a meeting since admission. Interviews with staff confirmed the absence of documentation, contrary to the facility's policy of holding care conferences at least quarterly.
A resident with intact cognition and multiple diagnoses was observed without privacy while on the commode, visible to the hallway and roommate. Staff reported inadequate curtain coverage, a known issue to management, persisting for two years. The DON was unaware of the privacy issue, contrary to facility policy.
A facility failed to provide planned restorative exercises for a resident with cognitive impairment and functional limitations due to a stroke. The care plan included specific exercises and assistance, but these were not documented or implemented. The resident reported not using the exercise equipment, and staff confirmed the absence of a restorative therapy program.
A resident with a history of stroke and moderate cognitive impairment experienced delays in receiving toileting assistance, leading to incontinence and increased risk for UTI. Despite the care plan requiring staff assistance due to the resident's hemiplegia and hemiparesis, the resident's call light was left unanswered for an extended period, resulting in incontinence. Staff acknowledged the delay was due to insufficient staffing, contrary to the facility's incontinence management standard.
The facility failed to provide necessary psychiatric services to two residents due to operational issues. One resident, with intact cognition and multiple diagnoses, was not documented as having received psychotherapy as ordered. Another resident, with moderate cognitive impairment, was also not provided with ongoing psychiatric services as required. Both cases were affected by the facility's lack of a facilitator and internet connectivity issues, preventing successful telehealth visits.
A resident with severe cognitive impairment and specific dietary needs was not provided with the prescribed puree diet in a timely manner. On two occasions, the facility failed to prepare and serve the puree diet as required, with delays noted in meal preparation and service. The facility's policy mandates adherence to physician's dietary orders, which was not followed in this case.
A facility failed to ensure a legal representative signed an arbitration agreement for a resident with severe cognitive impairment, as indicated by a BIMS score of 4. The resident, diagnosed with aphasia, disorientation, and encephalopathy, signed the agreement without their representative's involvement. The facility lacked a specific policy on arbitration agreements and did not consult with residents or families for interpretation.
Instances were identified where residents on mechanically altered diets received food in inappropriate textures. One resident, recently upgraded from a pureed to a mechanical soft diet, experienced a choking episode when served meat cut up instead of ground. Another resident with moderate cognitive impairment and dysphagia was served a grilled cheese sandwich instead of the prescribed mechanical soft diet. Additional discrepancies were noted for other residents, indicating a pattern of non-compliance with dietary orders and insufficient oversight in food preparation and service processes.
The facility failed to provide adequate social services staff, leading to deficiencies in care planning and resident support. One resident was unaware of care conferences, another lacked a bed hold during a hospital transfer, and a third had an incomplete PASSR review. The Social Services Designee was unqualified and overburdened with multiple roles.
The facility failed to cover trash containers in the kitchen and the trash dumpster outside. Observations revealed an uncovered trash can under a table in the kitchen and an uncovered dumpster with garbage sticking up over the top. A CNA confirmed the dumpster was not covered. The Food Safety Code 2022 requires refuse to be stored in covered receptacles to prevent access by insects and rodents. The Administrator agreed that the trash should be covered.
The facility failed to maintain medical records that are complete, accurate, and readily accessible. The DON was unsure about the system for scanning documents into the EHR, and observations revealed boxes of unscanned records. Interviews indicated delays and inconsistencies in updating records, with some being outdated by 2-3 weeks. The facility lacked dedicated staff for medical records management, leading to incomplete and outdated records.
The facility failed to implement a comprehensive QAPI program with corporate governance and leadership oversight. The Administrator, who started her position in February 2023, reported that all policies are developed by the corporation and was unaware of how the corporation assists with leadership transitions. The deficiencies from the last recertification survey were not part of the facility's QAPI program.
The facility failed to provide an effective pest control program for flies, as evidenced by multiple observations of flies within the facility, including on a resident, in food, and in the kitchen. Interviews revealed that the facility did not have a specific contract for fly control, and the available treatment options were not in use.
The facility failed to maintain clean and safe windows, with observations of unclean and damaged windows in a resident's room and the kitchen. Staff interviews revealed inadequate cleaning schedules and unassigned inspection tasks, leading to pest entry points and unaddressed maintenance issues.
The facility failed to develop comprehensive care plans for several residents, omitting required PASRR services, therapy discharge recommendations, and information on high-risk medications and their side effects. The deficiencies were confirmed by the Regional Nurse Consultant and the Director of Nursing during interviews.
The facility failed to maintain acceptable nutritional status for four residents, with significant weight loss and discrepancies not promptly addressed. Policies requiring timely physician notification, re-weighing, and care plan updates were not followed.
The facility failed to post accurate nurse staffing data in a prominent location, as observations on two consecutive days revealed that the daily staffing sheets did not include hours worked. The facility also lacked a policy regarding daily staff posting, and the Director of Nursing indicated that the night shift nurse was responsible for this task.
The facility failed to employ a Certified Dietary Manager (CDM) on staff, necessary for food and nutrition services. The previous DM quit, and the new DM could not enroll in the required course until July. The Dietician confirmed the difficulty in finding certified individuals.
The facility failed to follow the menu as written for three meals, affecting the nutritional needs of residents. Staff did not check therapeutic menus for portion sizes or diet specifications, and residents received white bread instead of wheat bread as specified. The facility's policies on menus and therapeutic diets were not adhered to, leading to the observed deficiencies.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, leading to multiple food safety violations. Observations included improper food temperature checks, inadequate use of hair restraints, improper glove use, and unsanitary kitchen conditions.
The facility failed to securely attach handrails in the hallways, as observed when a handrail was found separated from the wall and rocking up and down when tested. The Maintenance Director confirmed the issue during a facility tour and interview, noting that monthly checks are performed on handrails. Facility policy requires handrail brackets to withstand a force of 200 lbs.
The facility failed to provide sufficient support personnel to safely and effectively carry out dietary services, including proper sanitation and food handling practices. Observations revealed a cluttered and dirty kitchen, improper food temperatures, and staff handling food with the same gloves after touching multiple surfaces. Additionally, a staff member from the laundry department assisted with breakfast without proper hair restraint and hygiene.
The facility failed to ensure that residents had access to the most recent COVID-19 vaccine. Clinical records lacked documentation of education, offer, or receipt of the vaccine. The DON stated the vaccine was not available until January, and the facility did not explore alternative procurement options after their pharmacy closed.
The facility failed to include a resident with moderately impaired cognition and multiple diagnoses in care conferences. The resident reported not knowing about care conferences and never being invited. The Care Conference Note lacked information about invitations, and the Social Services Designee confirmed the oversight.
The facility failed to provide written notice, including the reason for a room change, before a resident's room was changed. The resident, with intact cognition and multiple diagnoses, was moved to accommodate a new admission, but the required documentation and notifications were not completed.
The facility failed to provide a bed hold notice to a resident or the resident's representative when the resident, who had traumatic brain injury, seizure disorder, anxiety, and depression, was transferred to the hospital. The medical chart lacked documentation of the required bed hold notice, as confirmed by the DON.
The facility failed to perform elopement risk assessments for a resident with severely impaired cognition and multiple mental health diagnoses. Despite having a wander/elopement alarm, the resident walked out of the facility unassisted, and staff had to retrieve them. The DON and RNC admitted that the assessments were not performed as part of the resident's comprehensive quarterly assessments, and the content was insufficient to assess the risk accurately.
The facility failed to accurately complete MDS assessments for two residents, leading to incorrect documentation of a hip fracture and discharge details. The DON acknowledged that a newer staff member in the MDS nurse role contributed to these inaccuracies.
The facility failed to update care plans for three residents to include necessary fall and wound interventions. One resident with a wound lacked pressure-reducing devices in their care plan, another resident who experienced a fall had no intervention added, and a third resident's wound care plan was not updated promptly despite recommendations.
The facility failed to perform a recapitulation of a resident's stay at the time of discharge. The resident, with intact cognition and diagnoses of coronavirus and COPD, was discharged to home with necessary medical items and paperwork. However, the DON and RNC could not find additional information in the resident's record, and the facility's policies lacked clear criteria for discharge recapitulation.
The facility failed to notify a physician for the evaluation of significant weight loss for two residents with severe cognitive impairment and multiple diagnoses. Despite documented weight loss and a Nutrition Risk assessment, the clinical records lacked timely physician notification, and the facility's policy on Nutrition and Weight Management was not followed.
Failure to Protect Residents from Verbal and Mental Abuse
Penalty
Summary
The facility failed to protect residents from mental and verbal abuse, as evidenced by reports from six residents who experienced mistreatment by two staff members, Staff B and Staff C. These staff members were reported to have yelled at residents, delayed responding to call lights, and refused to assist residents with toileting needs, leading to incontinence episodes. Residents expressed feelings of worthlessness and, in one case, suicidal thoughts due to the staff's behavior. Despite residents reporting these issues to the administration, the mistreatment continued. Resident interviews revealed specific instances of abuse, such as Staff B and Staff C yelling at residents when they requested to use the phone or needed assistance. Residents reported that their call lights were often ignored for extended periods, and when staff did respond, they were verbally abusive. One resident described being pushed out of her room and denied the opportunity to comb her hair before being taken to the dining room. Another resident reported being called derogatory names by staff when asking for help with toileting. Staff interviews corroborated the residents' complaints, with several staff members acknowledging that Staff B and Staff C were known for their loud and abusive behavior. Despite these reports, the Director of Nursing (DON) and the Administrator claimed to be unaware of any issues, and there was no documentation of grievances or corrective actions taken. The facility's policy on abuse prevention was not effectively implemented, as the staff involved were not suspended pending investigation, and the residents' grievances were not addressed.
Failure to Report and Address Allegations of Abuse
Penalty
Summary
The facility staff failed to report instances of abuse, neglect, or theft to the facility administration, and the administration did not report these allegations to the Iowa Department of Inspections, Appeals, & Licensing (DIAL) within the required 2-hour timeframe. This deficiency affected six residents who were reviewed for abuse. The facility did not protect residents from abuse, as staff did not report allegations of mental and verbal abuse. A staff member witnessed two CNAs verbally abusing residents but did not report the incident. Multiple residents reported issues with specific staff members, Staff B and Staff C, who were accused of yelling at residents, refusing to allow phone use, delaying response to call lights, and denying bathroom access. These actions led to residents feeling neglected and, in some cases, experiencing incontinence. Residents expressed feelings of worthlessness and distress due to the treatment they received. Despite these complaints, the facility administration and Director of Nursing (DON) claimed to be unaware of any concerns regarding staff treatment of residents. Interviews with various staff members revealed that residents frequently complained about the behavior of Staff B and Staff C. Staff members reported these concerns to the DON and Administrator, but no changes were made. The facility's grievance records did not reflect any complaints, and the call light system did not record response times. The facility's policy required immediate reporting of abuse allegations, but this was not followed, and the allegations were not reported to the State Agency.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to protect residents from mental and verbal abuse by not investigating allegations against two staff members, Staff B and Staff C, who were accused of verbally and mentally abusing residents. Multiple residents, including those with no cognitive impairment, reported that these staff members yelled at them, refused to meet their needs, and made them wait excessively for assistance. Despite these reports, the administration did not conduct an investigation or implement protective measures to safeguard the residents during the investigation process. Resident interviews revealed consistent complaints about the behavior of Staff B and Staff C. Residents reported being yelled at, denied access to the bathroom, and made to feel worthless, leading to incontinence and emotional distress. Staff members also corroborated these claims, stating that residents frequently voiced concerns about the abusive behavior of Staff B and Staff C. Despite these reports, the Director of Nursing and the Administrator claimed to be unaware of any issues, and no formal investigation was initiated. The facility's policy required immediate notification and investigation of any allegations of abuse, but this was not followed. The facility lacked documentation of grievances or investigations related to the reported abuse. Interviews with staff indicated that complaints were made to management, but no action was taken. The facility's failure to investigate and address these allegations resulted in a deficiency, as they did not protect residents from potential abuse and did not adhere to their own policies for handling such situations.
Failure to Provide Appropriate Mechanical Soft Diets
Penalty
Summary
The facility failed to provide appropriate therapeutic diets to residents requiring mechanical soft diets, as observed during meal services on two separate occasions. On these dates, six residents, some of whom were moderately to severely cognitively impaired, were served food that did not meet their prescribed dietary texture. Specifically, residents were given BBQ shredded pork and pineapple chunks, which were not in accordance with their mechanical soft diet orders, posing a potential choking hazard. Interviews with staff revealed a lack of adherence to the dietary guidelines. Staff I, who was working as the cook, admitted to not grinding the BBQ shredded pork as required, citing concerns about the texture becoming too mushy. This decision was contrary to the facility's menu, which specified that the pork should be ground for residents on mechanical soft diets. Additionally, the facility's speech therapist and certified dietary manager confirmed that shredded meat and pineapple chunks were inappropriate for these residents, emphasizing the risk of choking. The facility's policies on therapeutic and mechanical soft diets were not followed, as evidenced by the inappropriate food textures served. The policies clearly stated that therapeutic diets must be prepared and served according to physician orders and regulatory standards. Despite these guidelines, the facility's failure to adhere to the prescribed diets resulted in an immediate jeopardy situation, as identified by the State Agency.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with a history of a Stage 4 pressure sore. The resident, who had severe cognitive impairment and was dependent on staff for personal care and mobility, was identified with an open area on the left inner buttock at the beginning of September 2024. Despite the Certified Nursing Assistant (CNA) staff reporting the issue to the nursing staff, the facility's records lacked assessments of the area, notification to the physician, and treatment orders until September 18, 2024. Observations on September 23, 2024, revealed that the resident's wound was open with no dressing in place, and slough was present in the wound. The nursing staff failed to complete the treatment as ordered. Interviews with staff indicated that the wound had been reported multiple times, but appropriate actions were not taken. The Director of Nursing (DON) acknowledged the need for prompt assessment and physician notification, but these steps were delayed, leading to the wound's deterioration. The facility's skin management protocol required staff to report any skin issues to the supervising nurse or wound care nurse immediately. However, this protocol was not followed, as evidenced by the lack of timely documentation and treatment. The resident's condition was further compromised by the failure to apply the prescribed dressing and treatment, despite multiple reminders from CNA staff. This inaction resulted in the State Agency identifying an Immediate Jeopardy situation, which remained unresolved at the time of the survey exit.
Deficiency in Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing and resident-centered activity program designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident. Observations revealed that the activity calendar outside resident doors had activities written on and taken off, with changes noted for the month of September. A bulletin board displayed outdated events from July and August. Interviews with the Activities Director, who is new to the position, indicated that she was unaware of any activities prior to her tenure, and the Administrator confirmed the absence of documentation for activities over the past six months. Further observations showed no structured activities taking place in the facility, with a Regional Nurse Consultant seen coloring with a resident in the living room area. A resident expressed feeling bored due to the lack of activities. The facility's policy on Activity Recreation Standards emphasized the importance of providing creative and comprehensive services to enhance residents' abilities, yet the facility did not adhere to this policy, as evidenced by the lack of structured activities and documentation.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, resulting in significant delays in responding to call lights, administering medications, providing wound care, and serving meals. Observations and interviews revealed that residents experienced prolonged wait times for assistance with toileting and transfers, with some residents waiting up to an hour or more. This delay in care led to incontinence episodes for some residents, causing distress and discomfort. The facility's census was reported to be 28 residents, and the staffing levels were insufficient to meet their needs. Several residents, including those with moderate cognitive impairments and those with intact cognition, reported issues with staff not responding promptly to call lights. In some cases, staff would turn off the call lights without providing the necessary assistance, leaving residents to wait for extended periods. This lack of timely response was observed across multiple days and shifts, indicating a systemic issue with staffing and care delivery. Residents expressed feelings of neglect and frustration due to the delays in receiving care. Staff interviews further highlighted the staffing challenges faced by the facility. A Licensed Practical Nurse (LPN) reported being the only nurse on the night shift, with only two Certified Nurse Aides (CNAs) available to assist residents. This staffing shortage resulted in delayed medication administration and meal service, with the LPN working extended hours to cover shifts. Additionally, a Registered Nurse (RN) reported struggling to complete wound care treatments due to extra resident needs and other responsibilities, further exacerbating the facility's inability to provide timely care.
Resource Mismanagement and Abuse in LTC Facility
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in multiple Immediate Jeopardy (IJ) level deficiencies. The deficiencies included failure to protect residents from mental and verbal abuse, as evidenced by six residents reporting concerns about staff treatment. Staff members did not respond to call lights for over an hour and yelled at residents during incontinence episodes, leading to feelings of worthlessness and suicidal thoughts among residents. Additionally, the facility failed to ensure all staff reported allegations of abuse, as a staff member witnessed verbal abuse but did not report it. Furthermore, the facility did not investigate allegations of abuse or separate the alleged abusers from residents, despite multiple staff members informing the administration of the incidents. The facility also failed to provide adequate care for a resident with a Stage 4 pressure sore that had reopened. The CNA staff identified the wound at the beginning of September, but the record lacked assessments, physician notification, or treatment orders until much later. Observations revealed the wound was not properly treated, with no dressing in place and slough present. This failure to prevent and treat pressure ulcers resulted in an IJ deficiency. Additionally, the facility did not have competent dietary staff to serve appropriate therapeutic diets, leading to residents receiving incorrect food textures, posing a choking hazard for those requiring mechanical soft diets. The facility's administration was further compromised by inadequate staffing and communication tools. The psychiatric provider was unable to review patient charts due to the lack of a facilitator and unreliable WIFI. Staff reported insufficient staffing levels, with the DON covering shifts as a CNA and night nurse. The facility also lacked functional internet, fax, and printer capabilities, hindering communication and access to current medical records. The administrator, responsible for two facilities, acknowledged the challenges of managing both locations and the ongoing staffing issues, which were exacerbated by the inability to secure temporary staff from agencies.
Failure to Secure Medical Records
Penalty
Summary
The facility failed to secure medical records of current and former residents, as observed during a survey. A storage room in the basement, identified as the medical records storage area, was found with its door open, allowing direct access from outside the building. Boxes and envelopes containing medical records were stored directly on the floor, some appearing to have been wet previously. Staff T, a Regional Nurse Consultant, confirmed the lack of security for these records, noting that the door from the outside did not lock, making the records accessible to anyone. Additionally, the facility lacked a policy on protecting and maintaining confidential medical records.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe and clean environment for its residents, as observed during a survey. In the basement, water was found sitting and coming over the edge towards the drain in the boiler room. Numerous items were observed lying on the floor in the storage area, including a wood pallet with boxes stacked on top, which had a black mold-like substance growing on it. Additionally, boxes appeared to have been wet and dried to the floor, and a piece of sheetrock was noted to have mold growing approximately 12 inches from the floor. Another piece of undetermined material was also found with mold-like substances growing on it and on the floor beneath it. Staff T, the Regional Nurse Consultant, confirmed that these items appeared to have been wet previously and had not been cleaned up, which was against the facility's policy for maintaining a safe resident care environment.
Failure to Provide Timely Access to Resident Funds
Penalty
Summary
The facility failed to honor the residents' right to manage their financial affairs by not providing timely access to their funds upon request. Three residents, all with a BIMS score of 15 indicating no cognitive impairment, reported difficulties in accessing their money. One resident mentioned that while they received money from the Administrator on a weekday, access was not guaranteed on weekends. Another resident, whose facility acts as their payee, expressed that they were unable to obtain money when requested. A third resident reported delays of 3 to 5 days in receiving requested funds and noted that money could only be accessed through the Administrator, who needed to visit the bank. Interviews with staff revealed that the facility maintained a small amount of money with the nurses, typically between $30.00 to $35.00, which was insufficient to meet residents' requests consistently. The facility's policy stated that residents should have access to their funds 24/7, yet this was not being adhered to. The Administrator acknowledged the issue, noting that the process involved replenishing the small sum of money with the nurses as needed, but this was not effectively ensuring residents' access to their funds as required.
Failure to Follow Physician's Orders for Two Residents
Penalty
Summary
The facility failed to follow physician's orders for two residents, leading to deficiencies in care. Resident #7, who had intact cognition and multiple diagnoses including hypertension, diabetes, and chronic kidney disease, was not weighed regularly as required. Despite a significant weight gain of 6.8 pounds over a few days, there was no documentation of Lasix administration, which was ordered to be given if the resident's weight increased by more than 2 pounds. The Registered Nurse was unaware of the Lasix order, and the Director of Nursing acknowledged that Resident #7 should have been weighed daily. Resident #29, also with intact cognition, had diagnoses including hypertension, diabetes, and malnutrition, and required tube feeding due to swallowing problems. The care plan directed staff to flush the gastric tube with 30 milliliters of water before and after feeding. However, during an observation, the RN only flushed with 15 milliliters of water before and after administering the enteral feeding. The Director of Nursing confirmed that the nurse should have followed the order to flush with 30 milliliters of water both before and after the feeding.
Failure to Provide Scheduled Baths Due to Staffing Shortages
Penalty
Summary
The facility failed to provide baths to residents according to their desired frequency, affecting 4 out of 5 residents reviewed. Resident #4, with intact cognition, reported not receiving baths twice a week as requested due to frequent low staffing. Observations confirmed the resident's hair was greasy, and staff interviews corroborated that residents often missed baths due to staffing shortages. The Weekly Bathing List showed Resident #4 missed 3 out of 9 scheduled baths, with no documentation of refusal in the progress notes. The facility's policy required at least two baths per week, but this was not adhered to. Resident #19, with moderate cognitive impairment, was observed with greasy hair and dirt under fingernails, having missed 3 out of 9 scheduled baths. Resident #5, with no cognitive impairment, required assistance with bathing and had only 3 baths documented in the past 30 days. Resident #9, with severe cognitive impairment, depended on staff for bathing and had only 1 bath in the previous 14 days. The facility's policy required at least two baths per week, but this standard was not met, as evidenced by the bathing records and staff reports of inadequate staffing.
Facility Lacks Dietary Manager and Adequate Kitchen Staff
Penalty
Summary
The facility failed to employ a Dietary Manager, resulting in insufficient staffing and inadequate training in the food and nutrition service department. The facility, with a census of 28, relied on a Licensed Nursing Home Administrator from a sister facility to cook due to a lack of available staff. The Administrator had requested help because the existing kitchen staff had not had a day off in a long time. The facility's staff was supposed to train with the visiting Administrator, but they called in sick, leaving the Administrator uncertain about who would cover the evening shift. Additionally, the facility's Housekeeping and Laundry Supervisor, who had no formal kitchen training, was called in to cook when there was no available cook. This supervisor had been working in the kitchen for approximately three weeks while also managing housekeeping and laundry duties, resulting in extended work hours. The facility had only two dietary staff, one of whom worked only on Wednesday evenings due to another job. The facility's Administrator acknowledged the absence of a Dietary Manager and mentioned that a Certified Dietary Manager from another facility occasionally assisted with inventory and kitchen duties.
Failure to Follow Planned Menu for Residents
Penalty
Summary
The facility staff failed to adhere to the planned menu for residents, which is a requirement to meet their nutritional needs. The planned menu for Week 2 Day 10 included BBQ pork, baked beans, glazed carrots, cornbread, margarine, and spiced peaches for the lunch meal. However, during observation, the meal served consisted of BBQ pork on a bun, a dinner roll with margarine, carrots, and peaches, deviating from the planned menu. The facility's policy states that menu planning is the responsibility of OptimaSolutions and the Dietary Manager, and it should meet the requirements of the Food and Nutrition Board of the Nutritional Research Council of the National Academy of Science. The Administrator confirmed that the only approved change was substituting cornbread with a dinner roll, indicating a failure to follow the set menu.
Failure to Serve Meals at Scheduled Times
Penalty
Summary
The facility failed to provide meals at regular times in accordance with resident needs, preferences, and requests, as observed during two separate occasions. On 9/15/24, the first lunch plate left the kitchen at 12:50 p.m., and the last meal tray was served at 1:50 p.m., despite the lunch meal being scheduled to be served at noon. Similarly, on 9/21/24, the first lunch plate left the kitchen at 12:41 p.m., and the last meal tray was served at 1:34 p.m. This was contrary to the facility's policy, which stated that meals should be served at regularly scheduled hours. An interview with a Certified Dietary Manager from another building confirmed that lunch should be served at noon.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared under sanitary conditions, as observed during a kitchen tour. The internal thermometer of the white kitchen fridge read 50 degrees, and various food items, including milk and juices, were stored without open dates. The freezer above the refrigerator contained items with ice crystals and no open dates. Staff L, the Licensed Nursing Home Administrator working as the cook, confirmed the milk temperature was 50 degrees and discarded all items in the refrigerator. Additionally, the stainless steel fridge had a dent and fluctuating temperatures, with the internal thermometer reading 52 degrees. Staff L admitted to not checking the temperatures of the units during her shift, leading to the disposal of all items stored in the refrigerator. Further observations revealed issues with other storage units. The chest freezer had significant ice buildup and a non-functional green light, with an internal temperature of 8 degrees. The outdoor freezer had icicles and ice buildup, with thawed food items inside. Staff L discarded all thawed food. Additionally, Staff U, the Maintenance Director, was seen in the kitchen without a hair net, and a food delivery was left outside in the sun for an extended period. The facility's policy on dietary infection control was reviewed, indicating the Dietary Manager's responsibility for maintaining sanitation, but Staff H expressed difficulty managing responsibilities across multiple buildings.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, as evidenced by multiple observations of staff not performing adequate hand hygiene, not using barriers under supplies, and not wearing appropriate personal protective equipment (PPE) during care for residents. For instance, a registered nurse was observed performing wound care on a resident with a history of MRSA without adequately washing her hands or changing gloves between tasks, which could potentially spread infection. Similarly, a certified nurse aide was seen emptying a catheter without using a barrier under the supplies and was unaware of the need for enhanced barrier precautions. Additionally, the facility did not maintain proper signage for enhanced barrier precautions, as observed in the case of a resident with an indwelling catheter. Staff failed to wear gowns during high-contact care activities, such as emptying catheter bags, despite care plans indicating the necessity for such precautions. This lack of adherence to PPE protocols was further highlighted when a staff member was seen wearing a PPE gown while moving through various areas of the facility, including clean storage and resident rooms, without changing the gown. The facility also used expired COVID-19 testing kits for both residents and staff who exhibited cold-like symptoms. This was acknowledged by the Director of Nursing and the Regional Nurse Consultant, who confirmed that the expired kits were used due to a lack of awareness and that new kits had been ordered. The use of expired tests could compromise the accuracy of COVID-19 testing results, potentially affecting infection control measures within the facility.
Mechanical Lift Maintenance Deficiency
Penalty
Summary
The facility failed to maintain mechanical lifts in good working order, compromising safe resident usage. Interviews with Certified Nursing Assistants (CNAs) revealed that the hand control of a mechanical lift was missing the up button, requiring staff to insert a finger into the hole to operate it. Additionally, the batteries of the lift did not charge well, often leaving the lift unusable when needed. Despite these issues being reported to the Maintenance Director multiple times, no corrective action had been taken. An observation confirmed the missing up button and a cracked bottom button on the hand control. The Maintenance Director, responsible for inspecting the mechanical lifts twice a week, admitted to not having documentation of these inspections and was unaware of the missing button. He claimed to have last checked the lifts on a previous date and found no issues. The facility's Administrator was also unaware of the problems with the lift and stated that the lifts are rentals, which should be fixed by contacting the rental company. The facility lacked a policy on equipment repair, and the user manual advised contacting an authorized distributor for repairs, highlighting the need for qualified personnel to service the lifts.
Failure to Conduct Care Conference for Resident
Penalty
Summary
The facility failed to conduct a care conference for a resident, which is a requirement for person-centered care planning. The resident, who has intact cognition as indicated by a BIMS score of 15, reported not remembering attending or being invited to a care conference. The resident's medical history includes hypertension, diabetes, hemiplegia, anxiety, and depression. A review of the resident's Electronic Health Record showed no documentation of a care conference since their admission. Interviews with the Nurse Consultant and the Director of Nursing confirmed the absence of such documentation, despite the facility's policy to hold care conferences at least quarterly or sooner if necessary.
Privacy Violation During Resident Care
Penalty
Summary
The facility failed to provide privacy during care for a resident, as observed during a survey. Resident #4, who has intact cognition and diagnoses including chronic pain, diabetes, bipolar disorder, psychotic disorder, and depression, was seen sitting on the commode without a privacy curtain, visible to both the hallway and their roommate. Staff members reported that the privacy curtain only covers half of the area, leaving the resident exposed, and stated that management is aware of the issue. The resident confirmed the lack of privacy during toileting, which has been ongoing for two years. The Director of Nursing was unaware of any rooms lacking proper privacy coverage, despite the facility's policy requiring staff to provide privacy during all procedures.
Failure to Implement Restorative Exercises for Resident
Penalty
Summary
The facility failed to provide restorative exercises as planned for a resident with moderate cognitive impairment and functional limitations in range of motion due to a stroke. The resident's care plan included specific interventions such as arm bike exercises, grip/pinch strengthening, and walking assistance, which were not documented or implemented. The resident reported not using the stationary or arm bike for some time, and the facility's electronic health record lacked entries for the restorative plan. Staff interviews revealed that the facility did not have a restorative therapy program in place at the time of the survey. The facility's policy stated that residents should receive individualized restorative nursing care to promote safety and independence, but this was not provided. The absence of a restorative program was confirmed by the Regional Nurse Consultant, indicating a systemic issue in the facility's approach to maintaining and improving residents' functional status.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely toileting assistance to a resident, leading to incontinence and an increased risk for urinary tract infection (UTI). The resident, who had a history of stroke and moderate cognitive impairment, was frequently incontinent of bladder but always continent of bowel. The care plan required staff assistance with toileting and peri-care due to the resident's hemiplegia and hemiparesis. Despite these needs, the resident experienced increased episodes of urinary incontinence and was prescribed antibiotics and antifungal medication for a UTI. On a specific day, the resident's call light was on for an extended period after breakfast, indicating a need to use the bathroom. The resident expressed that delays in assistance often resulted in incontinence. Staff E, a CNA, acknowledged the delay and attributed it to insufficient staffing. Staff G, an RN, agreed with this assessment. The facility's incontinence management standard aimed to ensure timely assistance and appropriate treatment to restore bladder function, but this was not achieved in this instance.
Failure to Provide Psychiatric Services Due to Operational Issues
Penalty
Summary
The facility failed to ensure that residents received necessary psychiatric services as recommended, affecting two residents. Resident #4, with intact cognition and diagnoses including chronic pain, diabetes, bipolar disorder, psychotic disorder, and depression, was ordered to see a psychiatrist for psychotherapy. However, the electronic health record lacked documentation of any psychotherapy sessions or follow-up. Attempts to provide psychiatric services were hindered by the facility's lack of a facilitator to assist the provider and persistent internet connectivity issues, which prevented successful telehealth visits. Similarly, Resident #8, who had moderate cognitive impairment and diagnoses including personality disorder, dysphagia, bipolar disorder, and depression, was supposed to receive ongoing psychiatric services as per the Preadmission and Resident Review (PASRR) evaluation. However, the same issues of unavailable facilitators and non-functional WIFI prevented the psychiatric provider from reviewing the patient's chart and conducting necessary visits. These deficiencies were confirmed through staff interviews and record reviews, highlighting the facility's failure to provide essential behavioral health care services.
Failure to Provide Prescribed Puree Diet
Penalty
Summary
The facility failed to provide a nourishing, well-balanced diet that meets the daily nutritional needs of a resident with severe cognitive impairment and a diagnosis of hypertension, Alzheimer's Disease, and abnormal weight loss. The resident was prescribed a puree texture diet, as documented in the facility's Order Listing Report. However, on two separate occasions, the facility did not prepare or serve the prescribed puree diet in a timely manner. On one occasion, the Licensed Nursing Home Administrator, who was working as the cook, admitted to not preparing the puree diet for breakfast. On another occasion, a dietary aide, who was a housekeeping staff member, had to request the cook to prepare the puree lunch meal, resulting in a delay in serving the meal to the resident. The facility's policy on the adequacy of diet states that residents' nutritional needs should be met in accordance with physician's orders, which was not adhered to in this instance.
Failure to Ensure Legal Representative Signs Arbitration Agreement for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident's legal representative signed a binding arbitration agreement when the resident had a cognitive impairment. This deficiency was identified for one of the three residents reviewed for arbitration agreements. The resident in question had a documented diagnosis of aphasia, disorientation, and encephalopathy, with a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Despite this, the resident signed the arbitration agreement without the involvement of their legal representative. The facility's President of Business Development and Marketing confirmed that there was no specific policy on arbitration agreements beyond what was included in the admission agreement, and the facility did not consult with residents or families to interpret the arbitration. The Director of Business Development acknowledged that a BIMS score of 4 was not adequate for understanding an arbitration agreement and admitted that the resident's representative should have been contacted.
Non-Compliance with Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that residents received food prepared in a form designed to meet their individual needs. Specifically, the report highlighted instances where residents on mechanically altered diets were served food in inappropriate textures. For example, Resident #9, who had recently upgraded from a pureed diet to a mechanical soft diet, experienced a choking episode when served meat cut up instead of ground as per the menu. This incident raised concerns about the facility's adherence to dietary requirements for residents with specific needs. Furthermore, Resident #7, who had moderate cognitive impairment and dysphagia, was served a grilled cheese sandwich instead of the appropriate meal on a mechanical soft diet during lunch service. The lack of documentation regarding education on the resident's diet further underscored the deficiencies in ensuring residents received food tailored to their dietary requirements. These lapses in serving appropriate textures and meals to residents with specific dietary needs indicate a systemic issue within the facility's food preparation and service processes. The report also highlighted instances involving other residents on mechanically altered diets, such as Residents #6, #10, #11, #17, #1, and #20, where there were discrepancies in the type of food served compared to their prescribed diets. These findings suggest a broader pattern of non-compliance with dietary orders and a lack of proper oversight in ensuring residents' nutritional needs were met according to their individual requirements. The failure to consistently provide food in the correct form to meet residents' dietary needs poses significant risks to their health and well-being, indicating a critical deficiency in the facility's food service practices.
Failure to Provide Adequate Social Services Staff
Penalty
Summary
The facility failed to provide adequate social services staff for three residents, leading to deficiencies in care planning and resident support. Resident #20 reported not being aware of care conferences and had never been invited to one. The Care Conference Note for this resident lacked documentation of an invitation to the care conference. Staff H, the Social Services Designee, confirmed that she had only been in the role for two months and that the previous Director of Nursing had managed care conferences before her tenure. Resident #25 did not have a bed hold obtained during a hospital transfer due to cognitive impairment. The clinical record lacked a social services assessment and did not list any resident contacts. Despite the resident expressing a desire to have family members listed as contacts, the DON reported that the resident did not want anyone involved in his care. Resident #26's PASSR indicated a need for a Level II onsite review, but the facility administrator was unaware of the scheduling for this review. Staff H, who was also the Activity Director and previously the Dietary Manager, reported having no qualifications for the Social Services Designee role and was managing multiple responsibilities without adequate training or support.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to cover trash containers in the kitchen and the trash dumpster outside the facility. Observations on multiple occasions revealed an uncovered trash can under a table in the kitchen, next to bulk flour storage. Additionally, the dumpster outside the facility was observed with garbage sticking up over the top and no cover. A Certified Nurse Assistant (CNA) working in the kitchen as a dietary aide confirmed the dumpster was not covered. The Food Safety Code 2022 requires refuse to be stored in receptacles or waste handling units that are inaccessible to insects and rodents and to be kept covered inside food establishments if they contain food residue and are not in continuous use, or after they are filled, and with tight-fitting lids if kept outside the food establishment. The Administrator agreed that the trash inside the kitchen and the dumpster outside the facility should be covered.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain medical records that are complete, accurate, readily accessible, and systematically organized. During an entrance conference, the DON reported that all resident records were located on the facility's EHR system, with no hard charts for residents. However, the DON was unsure if there was a system in place for documents waiting to be scanned into the EHR. Observations revealed boxes labeled 'scanned' in the DON's office, containing file folders and binders with resident information. Interviews with the Administrator and staff indicated delays and inconsistencies in scanning and updating medical records into the EHR, with some records being outdated by 2-3 weeks. The facility lacked dedicated staff for medical records management, relying on each department to scan their own records until recently assigning this task to a Registered Nurse as needed. The Health Information Management Manual directed that all records be readily accessible, systematically organized, and stored securely. It also required facility leadership to review and analyze the health information management process quarterly. However, the facility did not adhere to these guidelines, resulting in incomplete and outdated medical records. The Regional Nurse Consultant confirmed that the Progress Note for a resident's discharge did not satisfy the criteria for a discharge summary, and additional information could not be found in the boxes of medical records. This deficiency in maintaining accurate and complete medical records was evident in the cases of Resident #26 and Resident #3, where critical documentation was either delayed or missing.
Failure to Implement Comprehensive QAPI Program
Penalty
Summary
The facility failed to implement a comprehensive Quality Assurance and Performance Improvement (QAPI) program with corporate governance and leadership oversight. The Administrator, who started her position in February 2023 and received QAPI orientation in February 2024, reported that all facility policies are developed by the corporation and no policies are developed at the facility level. During the survey, the Administrator contacted the corporation for assistance, including ad hoc QAPI involvement. However, she was unaware of how the corporation assists with leadership transitions and admitted that she was learning as she went along. The Administrator also acknowledged that the deficiencies from the last recertification survey and the pattern of repeated deficiencies were not part of the facility's QAPI program, but she planned to bring the current survey's deficiencies to the QAPI program. The facility's QAPI Management Policy, dated January 2024, outlines the purpose and responsibilities of the QAPI program, including the development of plans for improvement and the submission of resident grievance/concern/complaint reports to the QAPI program coordinator. The policy also states that the governing body of the facility, represented by the Administrator, is ultimately responsible for the QAPI program. Despite these directives, the facility failed to adhere to its own policy, as evidenced by the Administrator's lack of knowledge and the absence of a comprehensive QAPI program addressing previous deficiencies. The facility reported a census of 29 residents at the time of the survey.
Failure to Provide Effective Pest Control Program for Flies
Penalty
Summary
The facility failed to provide an effective pest control program for flies, as evidenced by multiple observations of flies within the facility. On three separate occasions, flies were observed in various locations: one fly was seen being swatted away by a resident, another was found on the inside of aluminum foil covering ambrosia salad during evening meal service, and a third was inside an open bag of brown sugar in the kitchen. These observations indicate a persistent issue with flies within the facility, which was not adequately addressed by the current pest control measures in place. Interviews with the Administrator, Maintenance Director, and pest control staff revealed that the facility did not have a specific contract for fly control. The Administrator and Maintenance Director acknowledged the seasonal increase in flies due to nearby farming activities but were unsure if the recent pest control treatment included measures for flies. The pest control staff confirmed that the facility lacked a contract for fly-specific services and that the available treatment options, such as light-based glue traps, were not in use. The facility's policy from March 2016 emphasized the importance of pest control and the need for effective services, which were not being met in this case.
Failure to Maintain Clean and Safe Windows
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by multiple observations of unclean and damaged windows. In Resident #20's room, thick brown cobwebs, a pile of leaves, and a damaged window trim with exposed wood were observed. Additionally, the kitchen windows were found to be in poor condition, with one window having a 0.5-inch gap due to an unsecured screen, which was identified as a point of entry for flies. Loose brown debris and dry white spots were also noted on the inner sill of another kitchen window, and the lower rim of the window was dirty. Interviews with staff revealed that window cleaning was scheduled only twice a year, and the window inspection task, which was supposed to occur every three months, was not assigned to a specific staff member. The facility's Environmental/Plant Operations Policy emphasized the importance of pest control and maintaining clean windows, but these procedures were not effectively implemented. The Maintenance Director acknowledged the issues with wind in the area where Resident #20's room is located, but no immediate actions were taken to address the deficiencies observed during the survey.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in meeting their needs. For Resident #26, the care plan did not include specialized services as required by the Preadmission Screening and Resident Review (PASRR) Level II, such as psychiatric medication management, supportive counseling, and obtaining archived psychiatric records. This resident had diagnoses of depression, bipolar disorder, and multiple sclerosis, and was assessed to need these specialized services. The Regional Nurse Consultant acknowledged the omission during an interview. Similarly, Resident #5's care plan lacked therapy discharge recommendations, including a walk-to-dine program and a home exercise program, despite being discharged from physical and occupational therapy with these recommendations. The Director of Nursing and Regional Nurse Consultant confirmed these omissions during an interview. Additionally, the care plans for Residents #20 and #27 did not include information on high-risk medications and their side effects. Resident #20, who had moderately impaired cognition and was taking insulin and tramadol, did not have these medications' side effects listed in the care plan. Resident #27, with severely impaired cognition and taking melatonin, also lacked this information in the care plan. The Director of Nursing agreed that these side effects should have been included in the care plans during an interview.
Failure to Maintain Nutritional Status
Penalty
Summary
The facility failed to ensure residents maintained acceptable parameters of nutritional status for four residents. Resident #27 experienced significant weight loss over several months, with weights dropping from 195.4 lbs to 158.8 lbs. Despite the facility's policy requiring prompt action for significant weight loss, there was a lack of timely physician notification and intervention. The Regional Nurse Consultant acknowledged that the weight loss should have been addressed sooner. The facility's policy outlines specific steps for addressing weight loss, including RD consultation, MD notification, and care plan updates, which were not followed in this case. Resident #7 had a significant weight discrepancy, with weights recorded as 182.6 lbs and 275.4 lbs within a short period. The DON expected nurses to clarify such discrepancies, but there was no documentation of re-weighing or progress notes addressing the issue. The RNC mentioned that the scale had been calibrated after being moved, but the discrepancy remained unaddressed. The facility's policy requires re-weighing in case of significant weight changes, which was not done for this resident. Resident #11 experienced a weight loss of 6.58% over a month, with no weights taken after the initial loss. The resident's care plan lacked information and interventions to prevent further weight loss. Similarly, Resident #28 had a weight loss of 9.93% within a month, with no weekly weights taken as per facility policy. The care plan for Resident #28 also lacked information and interventions to address the weight loss. The facility's policy mandates routine weight monitoring and care plan updates for significant weight loss, which were not followed for these residents.
Failure to Post Accurate Nurse Staffing Data
Penalty
Summary
The facility failed to post accurate nurse staffing data in a prominent location and visible to residents and visitors. Observations on two consecutive days revealed that the daily staffing sheets did not include hours worked. Specifically, on 3/13/24 at 11:00 AM and on 3/14/24 at 10:31 AM, the staffing sheets dated for those respective days were missing the required hours worked information. Additionally, the facility did not have a policy regarding daily staff posting. An interview with the Director of Nursing on 3/14/24 at 2:00 PM indicated that the night shift nurse was responsible for completing the sheets daily, but this expectation was not being met.
Failure to Employ Certified Dietary Manager
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) on staff, which is necessary to carry out the functions of the food and nutrition service. The facility, with a census of 29 residents, could not enroll the Dietary Manager (DM) into a food service manager course until July, as the previous DM, who was in the class, quit working at the facility. The course registration form showed that the facility signed authorization for the DM's enrollment on 2/26/24, but the course only started in July. The Dietician confirmed that DMs are required to have certification as a CDM or certified food service manager (CFSM) upon hire, but such qualified individuals were hard to find.
Failure to Follow Menu and Therapeutic Diets
Penalty
Summary
The facility failed to follow the menu as written for three meals observed, affecting the nutritional needs of residents. On 3/11/24, the lunch menu included seasoned peas, wheat bread, and margarine. However, Staff G, the Dietary Manager, prepared peas for two residents on a pureed diet using beef broth and served mechanical soft diets peas instead of pureed peas as required. Staff H, the previous Dietary Manager, and Staff G did not check the therapeutic menu for portion sizes or diet specifications. Additionally, residents received white bread instead of wheat bread as specified in the menu. Staff H admitted to not checking the therapeutic menus and relying solely on the whiteboard for diet orders. The facility did not have diet cards, only the whiteboard for reference. On 3/12/24, the lunch menu included a wheat roll, but residents received white bread instead. Later that day, the dinner menu also included wheat bread, but Staff F, the Cook, and two dietary aides served white bread, stating it was all they had. The substitution notebook had no documented substitutions for March. The facility's undated policies on menus and therapeutic diets stated that menus must be followed as written and therapeutic diets must be prepared and served as ordered by the attending physician with supervision or consultation from a qualified dietician. The facility failed to adhere to these policies, leading to the observed deficiencies.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial tour of the kitchen, several deficiencies were observed, including a cluttered and dirty handwashing sink, open and undated packages of shredded cheese in the refrigerator, a slimy substance at the base of the fridge, and a food-crusted can opener. Additionally, the floor and areas underneath the counter were soiled, and the oven hood appeared grimy. The Dietary Manager (DM) and staff were observed handling food without proper temperature checks and using the same gloves after touching multiple surfaces, which is against food safety protocols. Staff also failed to use hair restraints effectively, and there were issues with the cleanliness of the kitchen environment, including an open window blowing into the kitchen and dirty dumpsters visible from the window. The facility's sanitation and infection control policy was not followed, as evidenced by the lack of proper cleaning schedules and procedures for kitchen equipment and areas. The DM was observed preparing pureed peas and ground chicken for residents on special diets without properly checking the food temperatures, which were found to be below the required 165 degrees for reheating. The food was reheated in the microwave but not consistently checked for proper temperature before serving. During meal service, staff continued to handle food with the same gloves after touching various surfaces, and a staff member with hair hanging out of her hair net was seen touching her face before serving a resident. Additionally, room trays sent out from the kitchen were missing drinks, and the food temperatures on these trays were found to be below the safe serving temperature. The facility's failure to adhere to the FDA Food Code 2017 and its own sanitation/infection control policy resulted in multiple food safety violations. These included improper reheating of food, inadequate use of hair restraints, improper use of gloves, and failure to maintain cold food at the required temperature. The facility's cleaning procedures for kitchen equipment and areas were also not followed, contributing to the overall unsanitary conditions observed in the kitchen.
Handrails Not Securely Attached in Hallways
Penalty
Summary
The facility failed to securely attach handrails in the hallways, as observed on 3/11/24 at 1:30 PM, where a handrail was found separated from the wall by 1/4 inch and rocked up and down when tested. During a facility tour and interview on 3/13/24 at 3:08 PM, the Maintenance Director confirmed that he performs monthly checks on handrails and agreed that the handrail in question needed repair. The facility's policy, dated 3/19/24, requires handrail brackets to be tightly secured to withstand a force of 200 lbs applied in a downward or outward direction.
Deficiencies in Dietary Services and Sanitation
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the dietary services, including sanitation, proper food handling practices, and maintaining appropriate food temperatures. During an initial tour of the kitchen, several deficiencies were observed, such as a cluttered and dirty handwashing sink, undated open packages of shredded cheese in the fridge, a slimy substance at the base of the fridge, a food-crusted can opener, and soiled floors. Additionally, the oven hood appeared grimy, and there was a pool of brown liquid underneath the counter. The Dietary Manager (DM) was observed placing pureed peas and ground chicken in the steam table without checking their temperatures, which were found to be below the required levels. The DM and other staff members were also seen handling food with the same gloves after touching multiple surfaces, indicating poor food handling practices. Further observations revealed that a staff member from the laundry department, who was assisting with breakfast, had hair hanging out of her hair net and touched her face before serving a resident. Additionally, room trays were brought out without drinks, and the food on the trays was found to be at an inadequate temperature. The facility's undated policy on Personnel Management stated that sufficient staff should be employed, oriented, trained, and scheduled to meet the nutritional needs of the residents and maintain the Dietary Department. However, the observations and staff interviews indicated that the facility failed to adhere to this policy, leading to the identified deficiencies.
Failure to Provide Access to Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to ensure that residents had access to the most recent COVID-19 vaccine for five residents. The clinical records for these residents lacked documentation that they, or their responsible party, had been educated on the 2023-2024 COVID-19 vaccination, been offered, or received even one dose of the vaccine. The Director of Nursing, new to the facility, stated that the newest COVID-19 vaccine was not available to them until January, and they were in the process of addressing this. The facility had been evacuated to a sister facility in January and returned on February 1, 2024. Additionally, the facility's pharmacy closed on February 17, 2024, and no alternative avenues for procuring the vaccine were explored, such as public health or other pharmacies. The CDC's updated guidelines recommended the 2023-2024 updated COVID-19 vaccines to protect against serious illness from COVID-19. The guidelines specified that everyone aged 5 years and older should get one dose of an updated COVID-19 vaccine, with additional doses recommended for certain populations. Despite these guidelines, the facility did not ensure that the residents were educated about or offered the updated vaccine, leading to a deficiency in providing adequate protection against COVID-19 for the residents reviewed.
Failure to Include Resident in Care Conferences
Penalty
Summary
The facility failed to include a resident or resident representative in care conferences for a resident with moderately impaired cognition, as indicated by a BIMS score of 12. The resident had diagnoses of stroke, hemiplegia or hemiparesis, bipolar disorder, and cognitive communication deficit. During an interview, the resident reported not knowing about care conferences and never being invited to one. The Care Conference Note lacked information about the resident or representative being invited. The Social Services Designee, who recently took over the role, confirmed that the previous DON managed care conferences and kept a binder of invitation letters, but agreed that the resident and representative should be invited to care conferences.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for a room change, before the resident's room was changed. Resident #19, who had intact cognition with a BIMS score of 15 and diagnoses of anxiety, depression, and schizophrenia, was moved to a new room on 2/15/24. The clinical record lacked documentation of written notification to the resident prior to the room change, and the only documentation available was a Health Status Note indicating the resident tolerated the new room and a Progress Note dated 2/26/24. The Administrator confirmed that the room change was made to accommodate a new female resident and acknowledged the lack of proper documentation. The facility's Notification of Room Change Policy, dated February 2015, outlines the steps required for notifying residents and their families about room changes, but these steps were not followed in this instance. The policy requires detailed documentation, including the reason for the room change and notification to the resident and their family, none of which were completed for Resident #19.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or the resident's representative when the resident was transferred to the hospital. The resident, who had diagnoses of traumatic brain injury, seizure disorder, anxiety, and depression, was transferred to the hospital as documented in progress notes. The resident's medical chart lacked documentation of a bed hold notice, which is required by the facility's policy. The Director of Nursing confirmed that the expectation is to complete a bed hold notice anytime a resident is discharged to the hospital or within twenty-four hours per their policy.
Failure to Perform Elopement Risk Assessments
Penalty
Summary
The facility failed to perform elopement risk assessments for a resident with severely impaired cognition and multiple mental health diagnoses, including anxiety, depression, bipolar disorder, psychotic disorder, schizophrenia, post-traumatic stress disorder, mild intellectual disabilities, and visual hallucinations. Despite the resident having a wander/elopement alarm used daily, the elopement risk assessments performed on various dates indicated that the resident was not at risk of elopement. However, on one occasion, the resident walked out of the facility unassisted, triggering the wander guard alarm, and staff had to retrieve the resident. The Director of Nursing (DON) and Regional Nurse Consultant (RNC) acknowledged that the resident's wanderguard order started on a specific date and continued despite some unknown changes to the order. They also admitted that the elopement risk assessments were not performed as part of the resident's comprehensive quarterly assessments. The RNC reported that the content of the elopement risk assessment was insufficient to provide an overall perspective of the resident's risk for elopement. The facility's policy directed that a comprehensive, accurate, standardized, and reproducible assessment of each resident's functional capacity should be conducted, including reassessments based on individual needs, which was not adhered to in this case.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for two residents. For one resident, the MDS indicated intact cognition and noted diagnoses of anxiety, depression, and schizophrenia. However, it incorrectly reported that the resident did not have any fractures related to a fall in the six months prior to admission, despite a physician's documentation of a hip fracture resulting from a fall. The resident had re-entered the facility on February 1, 2024, and the major injury determination form signed by a physician confirmed the fracture as a major injury from a fall on January 13, 2024. For another resident, the MDS also indicated intact cognition and noted diagnoses of coronavirus and chronic obstructive pulmonary disease (COPD). The MDS inaccurately documented the resident's discharge to a short-term general hospital without mentioning the call placed to home health regarding orders for home health assistance. The facility's policy requires comprehensive, accurate assessments, and the MDS Coordinator and Interdisciplinary Team (IDT) are responsible for ensuring accurate documentation. The Director of Nursing (DON) acknowledged that a newer staff member in the MDS nurse role contributed to these inaccuracies and mentioned plans for MDS training as a result of the survey findings.
Failure to Update Care Plans for Falls and Wounds
Penalty
Summary
The facility failed to revise and update the care plans for three residents to include necessary fall and wound interventions. Resident #10, who has a diagnosis of coronary artery disease, hypertension, and thyroid disorder, and a moderate cognitive impairment, had a wound on the left buttock. However, the care plan lacked information regarding pressure-reducing devices for the recliner and wheelchair. Resident #24, diagnosed with Alzheimer's Disease, hypertension, and hyperlipidemia, and with severe cognitive impairment, experienced an unwitnessed fall. The care plan did not include any intervention for this fall, and the Director of Nursing (DON) confirmed that no intervention was put in place at the time of the incident. Resident #3, with intact cognition and diagnoses including schizoaffective disorder, diabetes mellitus, and multiple sclerosis, had an abdominal wound that started on 1/4/24. The care plan intervention for this wound was not updated until 3/8/24, despite recommendations from the wound nurse on 1/4/24 to continue the current ostomy regimen with additional barrier strips. The DON stated that she would expect the care plan to reflect changes in the resident's condition promptly. The facility's policy on Care Planning Management requires that modifications, deletions, or additions to the care plan be made at the time of occurrence, especially in acute situations such as falls, new skin alterations, and other significant changes in resident conditions. The policy also mandates that care plans be accessible to clinical staff to facilitate timely updates. Despite this policy, the care plans for Residents #3, #10, and #24 were not updated promptly to include necessary interventions for falls and wounds, as confirmed by clinical record reviews, staff interviews, and the facility's own policy review.
Failure to Perform Recapitulation of Resident's Stay at Discharge
Penalty
Summary
The facility failed to perform a recapitulation of a resident's stay at the time of discharge for one resident. The resident, who had intact cognition and diagnoses of coronavirus and chronic obstructive pulmonary disease (COPD), was discharged to home with transportation provided by the resident's daughter. The discharge summary noted that future appointments, paperwork, inhalers, nebulizer treatments, and antibiotics for a dentist appointment were sent with the resident. However, during a review of the resident's progress notes, the Director of Nursing (DON) and Regional Nurse Consultant (RNC) were unable to find additional information that should have been included in the resident's record. The facility's policies on discharge did not provide clear criteria on what to include in a recapitulation of a resident's stay.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify a physician for the evaluation of significant weight loss for two residents. Resident #27, who had severe cognitive impairment and multiple diagnoses including renal failure, heart failure, and dysphagia, experienced a significant weight loss over several months. Despite the weight loss being documented in the Weight Log and noted in a Nutrition Risk assessment, the clinical record lacked timely physician notification. The Regional Nurse Consultant confirmed that the weight loss should have been addressed sooner than it was. The facility's policy on Nutrition and Weight Management was not followed, as there was no evidence of physician notification, family notification, or care plan updates in response to the weight loss. Similarly, Resident #11, who had severe cognitive impairment and diagnoses including seizure disorder and bipolar disorder, also experienced significant weight loss. The resident's weight dropped from 167.2 lbs to 156.2 lbs over a month, and no weights were taken after this date. The resident's care plan lacked information regarding the significant weight loss, and the clinical chart did not document physician notification. The Director of Nursing confirmed that the physician should have been notified of the significant weight loss. The facility's failure to follow its own policy resulted in a lack of timely medical intervention for the residents' weight loss.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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