Aspire Of Perry
Inspection history, citations, penalties and survey trends for this long-term care facility in Perry, Iowa.
- Location
- 2625 Iowa Street, Perry, Iowa 50220
- CMS Provider Number
- 165426
- Inspections on file
- 26
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Aspire Of Perry during CMS and state inspections, most recent first.
The facility failed to provide adequate nursing staff to meet residents’ daily care needs, resulting in prolonged call light response times and missed or delayed showers and hygiene care. Several cognitively intact residents reported waiting 20–30 minutes or longer for toileting and post-toileting assistance, and some described routinely long call light waits, including instances of an hour for care. Residents also reported missed scheduled showers attributed to short staffing, with one resident going a week without a shower and another not being offered a planned bath until an agency aide stayed over to complete it. Staffing records showed frequent days with fewer CNAs on duty than outlined in the facility’s own assessment and staffing plan, particularly on the day shift, and management staff confirmed that staffing had been “rough,” with non-nursing department heads regularly assisting on the floor and call light response times extending to 15–20 minutes despite a policy requiring immediate response and prompt completion of requests.
Staff failed to accurately document, reconcile, and handle controlled substances for several residents. For a hospice resident with chronic pain and anxiety, numerous doses of liquid morphine and lorazepam were inconsistently recorded between the controlled substance logs and the EMAR, with multiple mathematical and transcription errors in the narcotic counts and an apparent morphine shortage when the bottle was empty but the record showed remaining volume. During a narcotic count, a CMA had not yet signed out recently given tramadol, later back-entered doses, and a morphine count entry was altered without initials or explanation. Another resident received a pill that had been dropped on the medication cart and swept into a cup instead of being discarded, and a lorazepam bottle was used beyond 90 days before destruction. For an additional resident with chronic pain, the facility could not produce a required narcotic administration record and reconciliation for a delivered supply of Morphine ER, contrary to its own controlled substance policy.
The facility failed to follow dietitian-approved menus and recipes and did not consistently obtain RD approval for menu substitutions. A cook altered a planned ground beef stew and served canned stew instead, and residents complained when hamburger patties were used in place of corned beef for sandwiches. The Dietary Manager repeatedly substituted items when ingredients were missing or not ordered, including serving frozen pepperoni pizza instead of the planned menu item and using canned beef ravioli instead of a soup recipe, without reliably notifying the RD. These substitutions occurred despite residents having specific diet orders such as NAS, consistent carbohydrate, and small portions, and despite a facility policy requiring RD review of menus and documentation of any deviations.
The facility failed to maintain resident dignity and respect when the Administrator frequently used loud profanity, including the F word, in open areas where cognitively intact residents could hear. Multiple residents reported that the Administrator routinely swore in everyday conversation, talked loudly, and made at least one comment perceived as calling a resident a “poor bastard” in the dining room. A grievance from the resident council documented concerns about the Administrator and a previous DON cussing loudly in common areas. The ADON and Social Services Director corroborated that the Administrator and previous DON yelled and used profanity in locations audible to residents, and the Administrator admitted to being unprofessional at times and using profanity around residents, contrary to the facility’s dignity policy.
Surveyors found that two cognitively intact residents reported their mail was routinely opened by the Administrator before being delivered, including business correspondence such as Social Security mail. One resident stated this happened every time such mail arrived and that she felt her privacy was violated, while another reported the Administrator opened all of her mail and then characterized much of it as junk. Admission and facility forms showed mail was to be directed to the residents and delivered unopened, and neither resident’s care plan documented any request or preference for staff to open their mail. The Social Services Director and Administrator acknowledged that the Administrator opened business mail for residents for whom the facility was representative payee, despite a written policy requiring that mail be delivered unopened and only opened by staff upon resident request documented in the care plan.
A resident with intact cognition and multiple psychiatric and medical diagnoses, who required staff assistance for bathing and transfers, did not receive showers according to the documented care plan and shower schedule. Records showed showers were provided only twice during the review period despite a schedule for multiple weekly showers, and a grievance revealed that staffing shortages led to missed showers. The resident reported not refusing any showers and stated that staff documented refusals even when showers were not offered, while leadership acknowledged that scheduled baths were missed and that facility expectations for offering and documenting bathing and refusals were not followed.
A resident with intact cognition but significant physical limitations, including dependence for transfers and hemiparesis after a CVA, was assessed and care-planned to use a smoking apron due to balance problems, limited arm/hand range of motion, poor fine motor skills, and a tendency to drop ashes. Despite the facility’s smoking policy and the documented requirement for a safety device, surveyors observed the resident smoking independently in the courtyard on multiple occasions without the apron. A CNA who assisted the resident to smoke stated she did not offer the apron and was unaware it was required, and the ADON reported the resident sometimes refused the apron because it complicated smoking. This reflects a failure to consistently implement the resident’s assessed and care-planned smoking safety interventions.
Two residents experienced significant medication errors when staff failed to follow physician orders and facility policy for medication administration. One resident with chronic pain and a history of CVA was ordered Morphine ER three times daily plus PRN Morphine IR, but due to a shortage of the ER formulation and a failure to place the ER order on hold, a CMA repeatedly administered Morphine IR in place of the ER dose and documented it as ER on the MAR, resulting in multiple IR doses given too close together. Another resident with hypertension, kidney disease, and edema had alternating-day Potassium Chloride ER orders of 20 mEq and 40 mEq, but a nurse, confused by separate medication cards, administered only 20 mEq on a day 40 mEq was ordered, while documenting 40 mEq on the MAR. These events occurred despite a facility policy requiring verification of the five rights of medication administration.
Surveyors found that kitchen and dry storage areas were not maintained in a sanitary manner, including scoops stored directly in flour and sugar, food and single-serve items stored in cardboard boxes on the floor, and visible grime and debris on shelves, the top of a refrigerator holding boxed juices, and an A/C filter. During meal service, the Dietary Manager and a dietary cook prepared sandwiches on a prep table beneath a dirty metal shelf holding various items. Dietary staff and the Dietary Manager reported there was no formal cleaning schedule and that they "clean as we go," while a housekeeper could not recall the last time the dry storage floor was cleaned and stated she did not have a key to the locked room. The consultant RD agreed with concerns about general cleanliness, and the Administrator stated she expected daily, weekly, and monthly cleaning schedules, with these findings cited under the 2017 FDA Food Code.
A resident with an indwelling urinary catheter and nephrostomy tube, under Enhanced Barrier Precautions and with a history of UTI, required assistance with draining both devices. A CNA donned PPE in the hallway without performing hand hygiene, entered the room, assisted with positioning, and emptied the urinary catheter bag and then the nephrostomy bag using separate drainage cylinders placed on the floor, changing gloves between tasks but not performing hand hygiene until all tasks were completed. The CNA later acknowledged that hand hygiene should have been done before donning PPE and between emptying each bag, and the DON confirmed this expectation. Separately, the Administrator reported that infection prevention surveillance audits were performed but not documented, and there was no documented process surveillance to monitor staff compliance with infection prevention policies, despite a written policy requiring data collection when preventative measures are in place.
A deficiency was cited when staff transferred a resident with severe cognitive impairment, a left leg fracture, and a non–weight-bearing order from bed to wheelchair using a mechanical lift with the lift’s legs kept closed while raising, backing, turning, and moving the resident. The legs were only opened once the lift reached the front of the wheelchair, contrary to staff statements, facility policy, and the manufacturer’s instructions that the legs should be in the maximum open position during movement and only briefly closed to navigate barriers.
A resident with severe cognitive impairment, a leg fracture, stroke history, and constipation had an order for PRN opioid pain medication every four hours and a care plan directing staff to assess pain and administer pain meds per order. Despite repeatedly calling out and clearly requesting pain medication and a laxative over an extended period, and reporting severe pain rated 9.5/10, CNAs only told the resident they had informed the nurse while the CMA was observed performing non-clinical tasks before addressing the resident’s pain. The resident was transferred and seated in the dining area still without pain relief, and only later did the CMA offer and administer the ordered pain medication, which was then documented, contrary to the facility’s pain assessment and management policy.
A resident with diabetes, kidney failure, hypertension, and morbid obesity, who received daily insulin injections, was given 10 units of short-acting insulin with a flexpen by an RN using a previously opened multidose pen that was not dated as required by facility policy. The RN attached a new pen needle, dialed the dose, and injected the insulin into the resident’s upper arm without priming the needle, despite priming being part of proper insulin administration. The resident had reported elevated post-lunch blood sugars, and records showed lunchtime blood glucose values ranging from 166 mg/dL to 398 mg/dL. A CMA and the DON stated that staff are expected to verify the 5 rights of medication administration, date newly opened medications, and correctly assemble and prime insulin pens, which did not occur in this event.
The facility did not report an incident where one resident pulled another's hair following a verbal altercation in the dining room. Although the event was witnessed and reported to staff, and subsequently to the Administrator, the required notification to the State Agency was not made, contrary to facility policy regarding the reporting of suspected abuse or mistreatment.
A resident with a history of psychiatric disorders and high fall risk eloped from the facility after becoming agitated and repeatedly attempting to leave. Despite prior incidents and staff awareness of behavioral issues, the resident was able to access a key, disable the door alarm, and exit through a fenced patio while staff were occupied elsewhere. Staff were unclear about security procedures and the alarm system, and attempts to contact facility leadership were unsuccessful, resulting in law enforcement being called to locate the resident.
A resident with severe cognitive impairment, PICA, and a mechanical soft diet order was left unsupervised with a regular slice of pizza in their room, intended for staff. The resident, known for impulsive eating behaviors, accessed and consumed the pizza, leading to fatal choking despite immediate staff intervention. Staff interviews confirmed awareness of the resident's risks and facility policy prohibiting staff food in resident areas, but these were not followed, resulting in the incident.
Staff prepared pureed meals for several residents using unmeasured amounts of ingredients and did not use the required volume method to ensure equal portions. As a result, some residents received noticeably smaller servings, and there was not enough pureed food for all intended recipients. The deficiency was confirmed through observation, staff interviews, and policy review.
Staff did not consistently use required hair and beard coverings, handled food and food surfaces with bare hands, and transported uncovered food and drinks to residents' rooms. Facility policies required the use of protective coverings, hand hygiene, and covering food during transport, but these were not followed during meal service.
The facility failed to conduct care conferences and involve residents in their care planning, affecting four residents with intact cognition. Despite the facility's policy requiring resident participation, there was no documentation of care conferences in the residents' progress notes over the last five months. The administrator acknowledged the inconsistency in conducting care conferences.
The facility failed to hold quarterly QAPI meetings in 2024 and did not employ a qualified Infection Preventionist. The Interim DON confirmed the absence of an infection preventionist, and the facility's administrator has not implemented a formal QAPI program since starting in September 2024. The QAPI binder lacked signature sheets for early 2024, and the first available sheet did not list an Infection Preventionist. The second sheet showed the absence of the DON and nurses, with the Medical Director contacted late.
The facility did not have an antibiotic stewardship program in place for its 33 residents, as it failed to track antibiotic usage and infections. A resident was on Nitrofurantoin for UTI prophylaxis, but the facility could not provide antibiotic tracking logs for the year. The DON, new to the position, acknowledged the lack of tracking and planned to start in the following year. The facility's policy required infection tracking, but no documentation was available to confirm compliance.
The facility did not employ a qualified Infection Preventionist (IP) despite having a census of 33 residents. The Director of Nursing (DON) was enrolled in a course but did not have IP certification. The job description and policy outlined responsibilities for infection control, but the absence of a qualified IP indicates a failure to meet these responsibilities.
The facility failed to ensure residents had timely access to their personal funds, affecting 29 residents who relied on the facility for financial management. Interviews revealed delays in accessing funds, especially during weekends, due to limited petty cash supply. The facility's process involved a $300 petty cash limit, insufficient for simultaneous requests, and checks for amounts over $99 took 48 hours to process.
The facility failed to maintain a clean and homelike environment, with strong ammonia odors detected in hallways and physical disrepair observed in the east hallway and shower room. The DON acknowledged the issue of urine smell, and observations noted broken furniture, chipped paint, and missing tiles.
The facility failed to verify background checks and certifications for staff, resulting in an agency CNA with a suspended certification due to abuse working shifts, and a DON starting work before her background check was completed. Staff B struggled with medication administration due to lack of orientation, and the facility's policy on abuse prevention was not followed.
The facility failed to complete and transmit Quarterly MDS Assessments for several residents within the required timeframe. The assessments were marked as 'In Progress' beyond the 14-day completion window, with many sections incomplete. The DON attempted to assume MDS duties due to the absence of an MDS Coordinator but was locked out of the system, contributing to the delay.
The facility failed to provide a Restorative Program for six residents requiring assistance with ADLs, as indicated by their MDS assessments. Despite their needs for supervision or assistance with mobility and daily tasks, none received Restorative Therapy services, and their care plans lacked restorative nursing programs. The DON confirmed the absence of a Restorative Aide and that no restorative programs were being conducted by staff, contrary to the facility's policy.
The facility failed to maintain a clean kitchen and proper sanitation practices. Observations revealed peeling paint on countertops, chipped doors, dirty floors, and inadequate dishwasher temperatures. Staff mishandled food by placing utensils and bread on unclean surfaces without barriers, and improper glove use was noted. The Dietary Manager acknowledged these issues.
The facility failed to follow infection control standards during the care of a resident with severe cognitive impairment and a feeding tube, as staff did not use required PPE. Additionally, the ice machine was not properly sanitized, and a CMA contaminated a glass of water during medication administration. The facility also lacked a comprehensive water management plan to minimize pathogen risks, and infection control audits were not properly documented.
A facility failed to implement interventions after an incident where a resident touched another resident's buttocks, making her uncomfortable. Both residents were cognitively intact, with one having behavioral symptoms and the other experiencing delusions. The facility did not promptly separate the residents or update their care plans, and staff were not adequately informed or educated about the incident. The facility's policy on resident altercations was not followed, leading to a deficiency in safeguarding resident dignity.
The facility failed to implement safety interventions for a resident who vapes and did not ensure appropriate supervision for a resident attending an external appointment. A resident's EHR lacked a vaping assessment, contrary to the facility's policy. Another resident left for a cardiologist appointment unaccompanied, despite needing assistance, which was acknowledged by the DON.
The facility failed to notify two residents and their families about financial responsibility when Medicare Part A services were ending. One resident lacked a signed CMS-10055 form, while another had an incomplete form. The social worker admitted to not presenting necessary information, including daily rates and appeal options, as required by facility policy.
The facility failed to complete and transmit Comprehensive MDS Assessments within federal guidelines for three residents. Two residents had incomplete Annual MDS assessments, and one resident's Admission MDS was completed late. The Director of Nursing acknowledged the delay, citing the absence of an MDS Coordinator and system access issues.
The facility failed to complete and transmit Comprehensive MDS Assessments for three residents following their enrollment in hospice care. A resident's MDS was completed three and a half weeks after hospice admission, while two other residents' MDS assessments remained incomplete weeks after their hospice enrollment. The Director of Nursing acknowledged the delay due to the absence of an MDS Coordinator and system access issues.
The facility failed to complete and transmit MDS Assessments within federal guidelines for two residents. One resident's Discharge MDS was incomplete weeks after discharge, and another resident's quarterly MDS was not transmitted to CMS within the required timeframe. The DON is attempting to manage MDS duties due to the absence of an MDS Coordinator and is currently locked out of the system, contributing to the delay.
A facility failed to include a resident's diabetes diagnosis and insulin orders in their care plan, despite the resident receiving insulin injections. The care plan did not reflect the resident's medical needs as required by facility policy, which mandates comprehensive and individualized care plans based on thorough assessments.
A facility failed to update a resident's care plan to include instructions and safety interventions for vaping. The resident occasionally vapes, but their care plan lacked specific guidance on this behavior. The facility's policies required evaluations for safe smoking and comprehensive care plans to address identified problems, but these were not applied to the resident's vaping habits.
A facility failed to attempt a Gradual Dose Reduction (GDR) for a resident on Seroquel, despite policy requirements for routine monitoring and consideration of GDR. The resident, with severe cognitive impairment, was receiving the medication daily, and a telemedicine psychiatric consultation advised against GDR to prevent decompensation. However, the facility did not document any rationale for not attempting a GDR, resulting in a deficiency.
The facility failed to document narcotic use accurately and did not destroy discontinued narcotics for two residents. A resident's Tramadol was not destroyed after discontinuation, and discrepancies were found between the CMUR and MAR. Another resident had expired Ativan orders in the narcotic drawer, despite being on hospice care and not swallowing pills. The DON acknowledged these medications should have been destroyed.
The facility failed to provide therapeutic meals as ordered for three residents with altered diets. A resident on a pureed diet was served breakfast with visible chunks, while two residents on mechanically altered diets were served crispy garlic toast. The staff's lack of understanding of the IDDSI codes contributed to the incorrect meal preparation.
A facility failed to administer a pneumococcal vaccine to a resident who had consented to receive it. The resident, undergoing cancer treatment, had an intact cognitive ability and was independent in daily activities. Despite the Power of Attorney signing an informed consent, the vaccine was not given, and the DON was unaware of the reason for this oversight.
The facility failed to administer the COVID-19 booster to two residents who had consented to receive it. One resident, with a history of chronic conditions and previous COVID-19 infection, and another with severe cognitive deficits, did not receive the booster despite signed consent forms. The interim DON acknowledged the oversight, and the facility's policy indicated vaccinations would be offered per guidelines, but the booster was not administered in 2023 or 2024.
The facility did not complete a necessary facility-wide assessment to ensure adequate resources for resident care. The DON identified the lack of an assessment but had not completed it by the survey date, despite planning to do so by the end of the month. The facility had 33 residents at the time.
The facility did not have an effective QAPI program in place, as identified by the DON who started in November 2024. Despite having a QAPI plan, it was not being completed. The absence of the program was noted on November 22, 2024, with plans to start monthly meetings in January 2024.
The facility failed to implement its QAPI program, resulting in no monitoring of adverse events, systematic analysis, systemic actions, program activities, and quality assessment and assurance. The DON, who started in November 2024, identified the absence of a QAPI program and confirmed that although a plan existed, it was not being completed. The facility had 33 residents.
A resident with severe cognitive impairment and multiple diagnoses experienced a verbal altercation with a CNA, who allegedly used profanity. The resident preferred assistance from another CNA and was found crying after the incident. Staff interviews provided conflicting accounts, but the facility's policy on resident rights was not upheld, leading to a deficiency finding.
A resident with cerebral palsy and other conditions was prescribed Cipro for a UTI, but the facility failed to notify the physician that the antibiotic was resistant to the microorganism identified. This oversight occurred twice, leading to continued urinary issues and incontinence. The facility did not adhere to its antibiotic stewardship program, which required monitoring and reporting of antibiotic resistance.
The facility failed to provide sufficient nursing staff, resulting in delayed or missed care for residents. A resident reported long wait times for call lights, while two others did not receive scheduled showers for a month. Staff interviews confirmed staffing shortages due to call-ins and financial issues with agency staff. The Administrator acknowledged concerns about staffing and its impact on resident care.
The facility failed to report and investigate abuse allegations timely and did not protect residents from potential misappropriation of funds. A staff member held a resident's funds at home, violating policy, and the facility did not implement a plan of correction for previous deficiencies.
The facility experienced a persistent mice infestation, with multiple residents reporting sightings and droppings in their rooms and common areas. Despite efforts to place traps and use steel wool to block entry points, the issue remained unresolved. Interviews revealed inconsistencies in pest control measures, with conflicting accounts of their frequency and effectiveness. The facility's pest control policy emphasized immediate action, but implementation was inadequate, and there was no comprehensive plan to address the root causes of the infestation.
Insufficient Nursing Staff Leading to Delayed Call Light Response and Missed Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs in a timely manner, resulting in delayed responses to call lights and missed or delayed bathing and hygiene care. Multiple cognitively intact residents, as evidenced by BIMS scores of 14–15, reported extended wait times for assistance and missed showers. One resident stated she waited about 20 minutes after activating her call light to use the commode and ultimately had to go to the nurses’ station to find staff to bring in her commode; she also reported waiting approximately 30 minutes on other occasions for post-toileting hygiene assistance and documented specific dates when this occurred. Another resident reported missing showers because the facility was short staffed and stated that records showed her as refusing showers even though they were not offered; facility grievance documentation confirmed that this resident did not receive a shower for one week and that the last shower documented for her was several days earlier. Additional residents described frequent long call light response times and inadequate staffing patterns. One resident reported that when staff were busy putting other residents to bed, she was told she would have to wait, and she stated that long call light waits of over 15 minutes occurred daily, with her roommate reportedly waiting up to an hour for care. She also reported that typical staffing consisted of two CNAs, one CMA, and one nurse, and that on the day of the survey there were five CNAs on the floor, which she believed was due to the surveyors’ presence. Another resident reported not being offered a scheduled bath on a specific evening due to staffing issues related to staff call-ins; she stated that an agency aide had to stay over on a later date to provide her second shower of the week and described feeling unclean, with stringy hair and itching skin. She also reported that staffing had been poor enough that the HR staff member had to work on the floor. Review of facility staffing records and interviews with staff and management corroborated that staffing levels were frequently below the facility’s own assessment and staffing plan. The facility assessment for a census of 32 residents called for four CNAs on dayshift, three on evenings, and two on nights, along with one nurse on each shift and a CMA on days and evenings. However, daily nursing assignment sheets for multiple dates showed only one to three CNAs on the day shift, with additional CNAs not starting until mid-morning on some days, and some days with as few as one CNA for part of the shift. The Social Services Director reported that staffing had been “very rough,” with dayshift sometimes having only one or two CNAs, requiring her and the HR Director, both CNAs, to help on the floor and resulting in call light response times of 15–20 minutes. The Administrator acknowledged that dayshift staffing had been “sketchy and rough,” particularly from 6 a.m. to 10 a.m., and that management staff, including herself, HR, and Social Services, often had to assist with direct care. The ADON stated that the expectation was to answer call lights as soon as possible within 15 minutes, but that there had been resident complaints about long call light waits on days with fewer than three CNAs, and that call lights were more problematic on weekends. The facility’s call light policy required immediate response and completion of resident requests within five minutes when possible, which was not consistently achieved under the documented staffing conditions.
Controlled substance documentation, reconciliation, and handling failures
Penalty
Summary
Facility staff failed to accurately document the administration of controlled substances, including morphine and lorazepam, on both the controlled substance records and the electronic Medication Administration Record (MAR/EMAR) for multiple residents. For one resident with cerebrovascular accident, hemiplegia, chronic pain, and hospice status, staff frequently administered liquid morphine 0.25 ml sublingually every 2 hours PRN for pain or shortness of breath and lorazepam 0.5 ml PO every 2 hours PRN for restlessness or anxiety. However, numerous doses of lorazepam were signed out on the controlled medication record but not recorded on the MAR, and other doses were documented on the MAR but not signed out on the controlled substance record. For the same resident, large numbers of liquid morphine doses were signed out on the controlled medication utilization record but not documented on the MAR, and there were multiple mathematical and transcription errors in the running counts, including repeated remaining amounts, over-subtraction, and unaccounted volume discrepancies. These documentation failures led to an apparent shortage of 1.5 ml of morphine when the bottle was empty but the count showed medication remaining, and an internal investigation later identified multiple transcription and subtraction errors and mismatches between the paper administration record and the EMAR. During a narcotic count observation with a certified medication aide, the surveyor identified additional discrepancies involving another resident’s tramadol 50 mg in a bubble pack. The bubble pack showed 6 tablets remaining while the controlled medication utilization record showed 8 tablets remaining. The aide stated she had just given the medication and had not yet signed it out on the controlled medication form, then entered two doses on the controlled medication form and later documented the administration in the EMAR hours after the actual administration time. For the same narcotic count, the surveyor also noted a discrepancy on the liquid morphine record for the hospice resident: a dose was signed out with an amount remaining of 29.75 ml, which was then crossed off and changed to 30 ml under the “wasted” column without initials or explanation. These findings showed that staff did not consistently sign out controlled substances at the time of administration and did not maintain clear, accurate, and contemporaneous controlled substance records as required by facility policy. The facility also failed to ensure proper handling and disposal of medications during administration. For a resident with hypertension, pain, and depression, a certified medication aide prepared multiple oral medications from bubble packs and delivered them to the resident. The resident noticed that one yellow pill was missing, and the aide returned to the cart, found the partially punched bubble pack, and pushed the pill out, causing it to fall onto the top of the medication cart. Instead of discarding the dropped pill, the aide swept it across the cart surface into a medication cup and then administered it to the resident. The administrator reported that if a pill was dropped on the medication cart, staff could ask the resident if they were okay with taking it or otherwise destroy the pill and obtain a new one, while the former DON stated she expected staff to waste any dropped medication. Additionally, the facility failed to destroy a controlled substance (lorazepam) after 90 days, as the controlled medication record showed a 30 ml bottle received and used beyond 90 days before the remaining 13 ml was destroyed. For another resident with diabetes, arthritis, stroke with hemiparesis, and chronic pain, the facility failed to complete and retain a narcotic administration record and reconciliation for a shipment of Morphine Sulfate ER 15 mg tablets. The MAR directed staff to administer Morphine Sulfate ER 15 mg three times daily and Morphine Sulfate 15 mg every 12 hours PRN for chronic pain, and a shipment summary confirmed that 30 tablets of Morphine Sulfate ER were delivered. However, the clinical record lacked a narcotic administration record and reconciliation for this controlled substance, and facility leadership confirmed that the narcotic administration record for this delivery could not be located. The facility’s controlled substances policy required that controlled substances be counted upon delivery, documented on a designated controlled substance record, and that an individual resident controlled substance record be created for each resident receiving a controlled substance, but this process was not followed or the documentation was not retained for this resident’s Morphine ER.
Unapproved Menu Substitutions and Failure to Follow Dietitian-Approved Recipes
Penalty
Summary
The deficiency involves the facility’s failure to ensure that menus and recipes were followed and that meal substitutions were approved by the Registered Dietitian (RD) to meet residents’ nutritional needs. Facility records showed that a cook changed the menu and did not prepare ground beef stew according to the recipe, instead serving canned beef stew. Resident council later complained that hamburger patties were used to make sandwiches in place of corned beef, and this complaint was confirmed. The Dietary Manager also made substitutions to the menu without consulting the RD and made unauthorized food purchases, including frozen pepperoni pizzas when the facility lacked pizza crust to prepare the planned menu item. Interviews with staff revealed that menu substitutions occurred due to last-minute changes, missing items from food deliveries, or ordering errors by the Dietary Manager, and that the RD was not consistently notified when these substitutions occurred. The Social Services Director reported that menu substitutions happened about every other week and that she did not believe the RD was always informed. The Dietary Manager acknowledged that when ingredients were missing or not ordered, the kitchen would “switch it up,” including using frozen pizza instead of making pizza per the approved menu and recipe, and serving canned beef ravioli instead of following a soup recipe. The RD reported concerns that the Dietary Manager was not ordering the correct amount of food, was purchasing other products, and was not informing her regularly of menu substitutions, despite prior meetings to clarify expectations for RD notification. The RD specifically cited the frozen pizza substitution as problematic due to residents with weight loss goals and fluid retention, and noted that simply removing pepperoni from the pizza for a resident on a no added salt (NAS) diet was not ideal. Review of facility documents showed that on the date pepperoni pizza was on the menu, there were residents on NAS, consistent carbohydrate, and small portion diets, and the facility’s own menu policy required RD review and approval of menus and documentation of deviations from posted menus, including reasons for substitutions, which was not consistently followed.
Failure to Maintain Resident Dignity Due to Administrator’s Profanity and Unprofessional Conduct
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect, specifically related to the Administrator’s use of profanity and loud, unprofessional communication in areas where residents were present. Three cognitively intact residents, each with a Brief Interview for Mental Status (BIMS) score of 15, reported that the Administrator frequently used swear words, including the F word, in everyday conversation within the facility. One resident stated the Administrator used profanity “all the time” in open areas in front of residents and that this concern had been raised through grievances and at a resident council meeting. Another resident reported hearing the Administrator refer to a resident as a “poor bastard” in the dining room, and described the Administrator as demeaning toward residents and staff. A third resident reported that the Administrator talked loudly, was distracting, and regularly swore in everyday talk, and expressed a desire that the Administrator not return. Resident grievance/complaint forms documented concerns from the Resident Council that the Administrator and the previous DON were cussing loudly in the dining room and that the Administrator had called a resident a “bastard,” though the written grievance noted the Administrator’s comment was about her husband being a “poor bastard.” A witness statement from the ADON described the Administrator as very loud and using profanity on many occasions with residents and staff, creating a tense atmosphere, and noted that residents had reported feeling bullied and talked down to by the Administrator. The Social Services Director also reported concerns about the Administrator’s professionalism, stating she had observed the Administrator and previous DON yelling and cussing at each other in open areas where residents could hear. The Administrator acknowledged being unprofessional at times, admitted to using profanity around residents and possibly using the F word in front of them, and stated that some staff also used profanity in the building. These actions conflicted with the facility’s dignity policy, which requires residents to be treated with dignity and respect at all times and cared for in a manner that promotes individuality, well-being, and self-esteem.
Failure to Protect Resident Privacy by Delivering Mail Already Opened
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received their mail unopened and with privacy. One cognitively intact resident, identified with a BIMS score of 15, reported that the Administrator consistently gave her mail after it had already been opened, specifically noting mail from the Social Security office. She stated that this occurred every time such mail arrived, that it had been gone through, and that she felt irritated and that her privacy had been violated because she wanted to see the contents before the Administrator did. Her admission documentation indicated all incoming mail was to be directed to her, and her care plan did not address any preference or request for staff to open her mail. The Social Worker later reported that the facility was not yet her representative payee at the time these events occurred. Another cognitively intact resident, also with a BIMS score of 15, reported that the Administrator opened all of her mail before delivering it and would tell her that most of it was junk after opening it. This resident stated that having her mail opened made her feel violated. A facility form titled "Mail Release" documented that this resident had given permission for staff to deliver unopened personal and business mail, and her care plan did not address any preference or request for staff to open her mail. The Social Services Director reported that the Administrator opened mail for residents, stating she was told this was done for residents for whom the facility was representative payee. The Administrator confirmed that she opened business mail for residents when the facility was representative payee, though she said she did not open personal mail and was not aware of the specifics of the facility policy. The facility’s written policy required that residents’ mail be delivered unopened and that staff only open mail upon resident request, with such requests documented in the care plan, which was not done for these residents.
Failure to Provide Scheduled Bathing Assistance to a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance according to the resident’s assessed needs, care plan, and established shower schedule. Resident #2 had an MDS indicating intact cognition with a BIMS score of 15 and required partial/moderate assistance for bathing and supervision/touching assistance for tub/shower transfers. Diagnoses included hypertension, difficulty walking, anxiety, depression, schizophrenia, and bipolar disorder. The resident’s care plan specified assistance of one staff member with washing, rinsing, drying, and dressing for showers, with a preference for scheduled showers two times per week and as needed. The facility’s shower schedule listed the resident for showers on the 6-2 shift on Tuesday, Thursday, and Saturday, with instructions that showers were not considered complete until a shower skin assessment was submitted to the charge nurse. Review of documentation showed that the resident received showers only on 3/3/26 and 3/11/26 during the review period, despite being scheduled for more frequent showers. A grievance form dated 3/11/26 documented that the resident had not received a shower for one week due to the facility being short staffed, and an audit of shower sheets confirmed the last documented shower was on 3/3/26. The resident reported that the shower on 3/11/26 was the first in 13 days, that she had missed one shower while at the hospital, and that on other days showers were not provided because the facility was short staffed. She stated she did not refuse any showers and that staff documented refusals even though showers were not offered. The ADON acknowledged that the resident did not receive scheduled baths on certain days and stated that showers/bathing were expected to be offered per the shower schedule, with at least one bath/shower per week and a bed bath offered if a shower was refused, and that refusals were to be documented with one attempt by the nurse, indicating that these expectations were not met for this resident.
Failure to Implement Required Smoking Safety Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement required smoking safety interventions for a resident assessed as needing a smoking apron. The resident had an MDS indicating intact cognition with a BIMs score of 14, but was dependent on staff for bed mobility and transfers and had diagnoses including diabetes mellitus, arthritis, CVA with hemiparesis, and adjustment disorder with mixed anxiety and depressed mood. The care plan identified a focus problem related to tobacco use and specified that the resident was to utilize a smoking apron. A Smoking and Safety Assessment documented that the resident had balance problems while sitting or standing, limited or no range of motion in arms or hands, insufficient fine motor skills to securely hold smoking items, and a tendency to drop ashes on self. The assessment concluded the resident was independent with smoking only with a required safety device, specifically a smoking apron. Despite these documented needs and care plan directives, surveyors observed the resident smoking independently in the courtyard on multiple occasions without wearing a smoking apron. On one occasion, a CNA reported assisting the resident outside to smoke and acknowledged she did not offer a smoking apron and was unaware the resident was supposed to use one. On another occasion, the ADON reported that when she offered the apron, the resident refused it, stating the apron complicated her ability to smoke. The facility’s Smoking/E-Smoking Policy required residents to be assessed for smoking safety and for identified provisions such as smoking aprons to be implemented, with noncompliance addressed through counseling and possible suspension of smoking privileges. The observations and staff interviews showed that the resident’s assessed and care-planned smoking safety intervention of a smoking apron was not consistently implemented.
Significant Medication Errors Involving Opioid and Potassium Dosing
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered by physicians, resulting in significant medication errors for two residents. One resident with intact cognition, diabetes mellitus, arthritis, CVA with hemiparesis, and chronic pain was ordered Morphine Sulfate ER 15 mg three times daily for chronic pain and Morphine Sulfate 15 mg every 12 hours PRN. The facility received notice from the pharmacy that the Morphine ER was not on hand due to a manufacturer delay, and the on-call provider directed staff to continue giving the PRN Morphine until the ER formulation was available. However, the nurse on duty did not place the Morphine ER order on hold, so it continued to appear on the MAR. On the day of the error, the CMA administered Morphine IR at 7:50 AM, 10:22 AM, and 1:00 PM, while signing off the doses as Morphine ER on the MAR, based on her understanding that the IR was being used in place of the ER and on the resident’s statement that she could take it every 8 hours like the ER medication. The clinical record lacked a narcotic utilization record for Morphine ER on the date of the error, while the narcotic record showed three doses of Morphine IR given in a short time frame. The February MAR documented Morphine ER as given that day at AM and noon, and Morphine IR as given at 7:49 AM, creating a discrepancy between what was documented and what was actually administered. The resident later reported that the CMA had given too many doses of Morphine IR in a short period, describing confusion about the day and feeling “so messed up,” and stated that the error was traumatic. The CMA acknowledged giving the Morphine IR too close together and not following the physician’s order, and reported that the nurse had instructed her to give the IR in place of the ER and was not helpful. Another nurse reported discovering from the narcotic record that three doses of Morphine IR had been given in a short period and notified facility leadership. For the second resident, who had intact cognition and diagnoses including hypertension, kidney disease, hyponatremia, and edema, the MAR contained two Potassium Chloride ER orders: 20 mEq once daily every other day for hypokalemia and 40 mEq once daily every other day for diuretic use. On one occasion, the resident reported receiving only 20 mEq instead of the ordered 40 mEq, stating she was supposed to get four potassium pills but only received two. A grievance and an incident report documented that the nurse had given only 20 mEq instead of 40 mEq, and that the medication card still contained the dose for that day. The nurse reported being confused by having separate medication cards for the alternating 20 mEq and 40 mEq days. The March MAR, however, showed Potassium 40 mEq signed off as administered on that date, indicating a discrepancy between the documented administration and the actual dose given. Facility policy required staff to administer medications as prescribed and to verify the right resident, medication, dosage, time, and route by checking the label three times before administration.
Failure to Maintain Sanitary Kitchen and Dry Storage Conditions
Penalty
Summary
Surveyors identified deficiencies in the facility’s kitchen and dry storage areas related to food safety and sanitation. In the main kitchen, a metal one-cup scoop with a black plastic handle was found sitting directly in a bag of stone ground whole wheat flour, and another metal one-cup scoop with a metal handle was found with its handle sitting in a bag of sugar. During observation of the dry storage room, eight cardboard boxes containing food and single-serve dinnerware were stored directly on the floor. A sticky fly strip hanging from the ceiling contained approximately half a dozen dead flies and numerous smaller mosquito-like insects. The floor of the dry storage room was stained with dried liquid residue and littered with cardboard remnants, tape, and a section of metal cove base lying on the floor. Later observation showed that while the fly strip and metal cove base had been removed, the eight boxes remained on the floor and the floor remained stained and littered with cardboard and tape. During noon meal service, the Dietary Manager and a dietary cook prepared sandwiches on a prep table in the kitchen that were served to residents, while the metal shelf above the prep table was noted to be dirty with grime and debris and holding various items including a plastic bag holder, hot pads, labels, a food cover, two dial weight scales, and three syrup containers. Grime and debris were also noted on top of the refrigerator containing boxed juices, and the air conditioner filter in the kitchen window had accumulated fuzzy debris. Dietary staff, including a cook employed for two months and a dietary aide employed for seven months, reported they were unaware of any cleaning schedule and stated they cleaned after each meal service. The Dietary Manager, in her role since May 2025, confirmed there was no formal cleaning schedule and that staff “clean as we go.” The consultant RD agreed with concerns about general cleanliness and stated she had discussed these concerns with the facility. The Dietary Manager acknowledged the dry storage room remained unclean and stated a housekeeper would clean the floor when needed, while the housekeeper could not recall the last time she cleaned that floor and reported the door was locked and she did not have a key. The Administrator stated she expected daily, weekly, and monthly cleaning schedules and referenced prior cleaning schedules seen in the kitchen. These conditions were cited against the 2017 FDA Food Code requirements for cleaning non–food-contact surfaces and maintaining a regular cleaning schedule.
Failure to Perform Hand Hygiene and Conduct Documented Infection Control Surveillance
Penalty
Summary
The deficiency involves the facility’s failure to implement infection prevention and control practices during the care of a resident with an indwelling urinary catheter and nephrostomy tube, as well as a failure to conduct documented infection control process surveillance. Resident #6, who had intact cognition with a BIMS score of 15, had diagnoses including hypertension, kidney failure, blocked urine flow, and non-Alzheimer’s dementia, and required assistance with draining his catheter bag and nephrostomy tube. The resident had an order for Enhanced Barrier Precautions related to catheter use and had a history of a UTI and an indwelling catheter with pus noted around the catheter. During a continuous observation, a CNA (Staff C) donned an isolation gown, gloves, and an ear loop mask in the hallway without performing hand hygiene before entering the resident’s room, despite an Enhanced Barrier Precautions sign directing that everyone must clean their hands before entering and when leaving the room. Once inside, the CNA moved the resident’s bedside table, assisted the resident in moving his legs off the bed, and proceeded to empty the urinary catheter bag into a drainage cylinder placed on the floor in a plastic bag. After emptying and cleaning the catheter spigot with an alcohol swab, the CNA moved the cylinder to the counter, then removed her gloves and put on new gloves without performing hand hygiene between these tasks. The CNA then placed the nephrostomy drainage cylinder on the floor in a plastic bag, opened the nephrostomy bag spigot, emptied it into the cylinder, wiped the spigot with an alcohol swab, measured the output, and emptied it into the toilet. She subsequently removed her gloves, tied the trash, replaced the trash bag, and only then performed hand hygiene with soap and water. The CNA later acknowledged she should have performed hand hygiene before donning PPE and between emptying each collection bag, and the DON confirmed staff should perform hand hygiene between glove changes and follow catheter care policy. Additionally, the Administrator reported that while she performed infection prevention surveillance audits, she did not document them, and there was no documented process surveillance to capture staff compliance with infection prevention practices, despite a facility policy stating that the infection preventionist collects data to determine the effectiveness of preventative measures when such precautions are implemented.
Improper Use of Mechanical Lift During Resident Transfer
Penalty
Summary
Surveyors identified a deficiency related to the unsafe use of a mechanical lift during a transfer. During observation, two CNAs transferred Resident #13 from bed to wheelchair using a mechanical lift with the lift’s legs kept closed while the resident was raised, backed away from the bed, turned, and moved toward the wheelchair. The legs of the lift were only opened once the device was positioned directly in front of the wheelchair to fit around it, rather than at the earliest opportunity after the lift was no longer under the bed. The resident’s care plan indicated he usually required two-person assistance with a mechanical lift for bed-to-chair transfers, and progress notes showed the facility used a mechanical lift to obtain his weight at admission. Resident #13 had a BIMS score of 5/15, indicating severely impaired cognition, and diagnoses including a left lower leg fracture, stroke, and constipation. A physician’s order directed that he remain non–weight bearing on his left lower leg for 8–12 weeks. Staff interviews confirmed that facility practice and training were that the mechanical lift’s legs should be opened when moving a resident and only closed briefly when necessary to accommodate barriers, with the DON stating staff should have opened the legs at the first available moment. The facility’s mechanical lift policy and the manufacturer’s user manual both specified that the lift legs must be in the maximum open position for optimum stability and safety, and that any closing of the legs under a bed should be temporary and reversed as soon as the lift is no longer under the bed.
Failure to Provide Timely PRN Pain Management for Resident With Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, ordered pain management to a resident with severe, frequent pain and significantly impaired cognition. The resident had diagnoses including a left lower leg bone fracture, stroke, and constipation, and the MDS showed he experienced frequent, severe pain that frequently affected sleep and almost constantly affected day-to-day activities. The EHR contained a physician’s order for an opioid every four hours as needed, and the care plan directed staff to administer pain medications per order if non-medication interventions were ineffective and to evaluate the resident’s pain. Progress notes showed the last pain medication was given shortly after midnight, and later that afternoon the resident was repeatedly heard and observed requesting pain medication and a laxative. From mid-afternoon onward, the resident called out for pain medication and, during multiple interactions with CNAs, clearly requested pain medication and something for constipation. Staff D and Staff E acknowledged his requests and stated they had informed the nurse, but the CMA was observed engaging in non-clinical activities such as serving popcorn and moving the popcorn machine before returning to the medication cart and going down another hall. During this time, the resident continued to report severe pain, rating it 9.5/10, and repeatedly stated he needed a pain pill and a laxative. He was transferred to his wheelchair and taken to the dining room, still without receiving pain medication, and only after this, when the CMA approached him at the table, was his pain medication finally administered and documented. The DON later stated staff should have consulted the nurse to immediately assess the resident’s pain and administer the ordered pain medication, and the facility’s pain policy required implementation of the medication regimen as ordered and ongoing assessment and documentation of pain and interventions.
Failure to Properly Date and Administer Insulin Using a Flexpen
Penalty
Summary
The deficiency involves the incorrect administration of insulin to a cognitively intact resident with diagnoses including hypertension, kidney failure, diabetes mellitus, and morbid obesity, who required insulin injections daily. The resident’s physician order directed staff to administer 10 units of short-acting insulin with meals using a flexpen, and the care plan instructed staff to check blood sugars as needed and administer insulin as ordered. The resident reported using insulin and experiencing elevated blood sugars after lunch, and the Treatment Administration Record showed lunchtime blood sugars ranging from 166 mg/dL to 398 mg/dL during the month. During a continuous medication observation, an RN prepared and administered the resident’s insulin using a flexpen that had been previously opened but was not dated, contrary to facility policy requiring multi-dose containers to be dated when opened. The RN attached a new pen needle, dialed the dose to 10 units, and injected the insulin into the resident’s upper arm without first priming the needle to remove air and ensure delivery of the full dose. After administration, the surveyor noted the absence of an open date on the pen, and the RN acknowledged that the pen should have been dated, that he had not checked the date before use, and that he had forgotten to prime the needle despite it being part of proper insulin administration. The CMA and DON both stated that staff are expected to verify medication rights, date newly opened medications, correctly assemble insulin pens, prime needles, and verify dates before administration, confirming that these steps were not followed in this instance.
Failure to Self-Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to self-report an incident involving two residents to the State Agency as required by policy. According to clinical record review, staff and resident interviews, and facility policy review, an altercation occurred in the dining room where one resident, who had cognitive impairment and a diagnosis of Alzheimer's Disease, was called a derogatory name by another resident, who then pulled the first resident's hair. This incident was witnessed by another resident, who reported it to the facility's social worker. The social worker, in turn, reported the event to the Administrator. Despite being informed of the incident, the Administrator did not report the altercation to the State Agency. The Administrator interviewed the involved residents, who did not recall the event, and contacted staff on the floor, none of whom had knowledge of the incident. The Administrator also decided not to interview the reporting resident due to concerns about her anxiety. The facility's policy requires immediate reporting of alleged violations related to mistreatment, neglect, or abuse, including resident-to-resident abuse, to the proper authorities, but this protocol was not followed in this case.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Lapses in Security
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent the elopement of a resident with a history of traumatic brain injury, psychotic disorder, schizophrenia, and bipolar disorder. The resident was assessed as high risk for falls due to psychotropic medication use but was not identified as at risk for elopement. Despite previous incidents where the resident attempted to leave the facility and staff intervention was required, the care plan and elopement evaluation did not reflect these behaviors, and no additional precautions were implemented. On the night of the incident, only one nurse and one CNA were present, and the nurse was unfamiliar with the overnight shift. The resident became agitated due to a lack of cigarettes, repeatedly attempted to leave, and was not successfully redirected by staff. During a period when both staff were occupied with another resident, the resident was left unsupervised and was able to access a key to disable the door alarm, exit through a fenced patio, and leave the premises. The alarm did not sound, and staff were unaware of the resident's departure until she could not be located. Attempts to contact the Administrator and DON were unsuccessful, and law enforcement was eventually notified. The resident was later found in a private home and transported to the hospital. Interviews revealed that staff were unclear about the location and control of keys, the function of the alarm system, and the facility's policy regarding elopement risk and supervision. The resident had a history of accessing restricted areas and items, and staff noted discrepancies in communication and documentation regarding her behaviors. The facility's policy required prompt reporting and intervention for residents attempting to leave, but these procedures were not effectively implemented, contributing to the resident's elopement.
Failure to Prevent Accidental Choking Due to Dietary and Supervision Lapses
Penalty
Summary
A cognitively impaired resident with diagnoses including autism, PICA, severe intellectual disabilities, and schizoaffective disorder was admitted to the facility and required one-person physical assistance with eating, a mechanical soft diet with ground meat, and visual supervision at all times. The resident was known to have behaviors such as putting hands in the mouth and attempting to take other residents' food, which placed him at risk for chewing problems and aspiration. Staff and care plans documented the need for close monitoring and adherence to dietary restrictions. On the day of the incident, the resident was observed attempting to take food from others in the dining room. Staff, including the Administrator and a Certified Medication Aide (CMA), decided to move the resident to his room for his meal. During this time, dietary staff delivered both the resident's prescribed mechanical soft diet and a regular slice of pizza intended for staff into the resident's room. The regular pizza was placed on the opposite side of the table, but the resident impulsively pushed the table, grabbed the pizza, and shoved the entire piece into his mouth. Despite immediate intervention with abdominal thrusts and a call to 911, the resident choked and subsequently died from food bolus asphyxia. Multiple staff interviews confirmed that staff were aware of the resident's dietary restrictions and behavioral risks, and that facility policy prohibited staff from eating in resident rooms or bringing personal food into resident areas. The presence of non-compliant food in the resident's environment, combined with insufficient supervision and failure to remove the hazard, directly led to the resident accessing and consuming food inconsistent with his prescribed diet, resulting in a fatal choking incident.
Failure to Accurately Portion Pureed Diets
Penalty
Summary
The facility failed to serve appropriate portions of pureed diets to five residents. During meal preparation, the cook and Certified Dietary Manager (CDM) prepared pureed fish, rolls, and coleslaw for five residents by blending unmeasured amounts of ingredients and water, without measuring the total volume of the pureed food. The staff then portioned the pureed food into serving dishes using a disher, but the last servings were noticeably smaller, and there was not enough pureed fish to serve all five residents. The CDM confirmed that the staff should have used the volume method to ensure equal and adequate portions, as outlined in the facility's policy, but the cook was unfamiliar with this method and had not been trained on it. Observations and interviews confirmed that the menu serving chart was used to select the disher size, but the actual volume of pureed food was not measured or divided equally among the residents. The deficiency was identified through direct observation of meal preparation, review of the resident diet list, and staff interviews, which revealed a lack of adherence to the facility's policy for pureed food preparation and portioning.
Failure to Maintain Sanitary Food Service Practices
Penalty
Summary
Staff failed to follow sanitary food service practices during meal preparation and distribution. The cook was observed preparing food without a beard covering, despite facility policy and orientation requiring the use of hairnets and beard restraints in the kitchen. The cook admitted to not wearing a beard cover, stating he was unaware it was necessary. The Certified Dietary Manager (CDM) confirmed that facial hair coverings are required at all times in the kitchen. During meal service, the cook handled resident bowls and plates with bare hands, with his thumb coming into direct contact with the food surface area. The CDM was also observed scooping pureed bread into a bowl with her thumb touching the food. Additionally, a dietary aide transported uncovered food items, including coleslaw, peach cobbler, and drinks, to multiple residents' rooms. The CDM stated that all food and drinks should be covered during transport and that non-food items should not come into contact with food or food surfaces. Facility policies reviewed indicated that hair and beard coverings must be worn, hands must be washed before contact with food surfaces, bare hand contact with food is prohibited, and food must be covered during transportation and distribution.
Failure to Conduct Resident Care Conferences
Penalty
Summary
The facility failed to conduct resident care conferences and offer residents participation in their plan of care for four residents. Each of these residents had intact cognition as indicated by their Brief Interview for Mental Status (BIMS) scores, yet they were not involved in care planning. Resident #2 recalled being invited to a care conference once, but it was canceled and never rescheduled. Resident #3 was unaware of what a care plan was and had never been invited to a care conference. Resident #4 had no memory of attending a care conference and was not aware of what it was. Similarly, Resident #5 was not aware of what a care conference was and did not recall attending one. The facility's policy on resident and family participation in care planning was not adhered to, as evidenced by the lack of documentation of care conferences in the residents' progress notes over the last five months. The policy required that residents and their representatives be invited to participate in care planning, be informed of their health status, and be allowed to view and sign their care plans. However, the facility's administrator acknowledged that care conferences had been inconsistent, and an audit revealed this deficiency. The facility's failure to conduct these conferences and involve residents in their care planning process led to the deficiency identified in the report.
Failure to Hold QAPI Meetings and Employ Infection Preventionist
Penalty
Summary
The facility failed to hold quarterly Quality Assurance Process Improvement (QAPI) meetings for the year 2024 and did not employ a required Quality Assessment & Assurance (QAA) committee member, specifically a qualified Infection Preventionist. The Interim Director of Nursing (DON) confirmed the absence of an infection preventionist, stating she is currently enrolled in a course to assume the role. The facility's administrator, who started in September 2024, has not implemented a formal QAPI program under his leadership. The facility reported a census of 33 residents. During the survey, it was found that the facility lacked an active QAPI program for monitoring and performance improvement project identification. The QAPI binder provided during the survey showed monthly signature sheets for meetings, but none were available for January through April 2024. The signature sheets for May, June, and July were incorrectly dated 2023. The first signature sheet for 2024 was dated August 30, 2024, and did not list a designated Infection Preventionist. The second sheet, dated September 27, 2024, showed that neither the DON nor any nurse attended, and the Medical Director was contacted an hour after the meeting began.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for all 33 residents, as evidenced by the lack of documentation and tracking of antibiotic usage. A review of a resident's Medication Administration Record revealed the resident was taking Nitrofurantoin for UTI prophylaxis, but the facility could not provide antibiotic tracking logs from January to December 2024. The Director of Nursing, who started in November 2024, admitted to not having tracked antibiotic usage and planned to start tracking in January 2025. Additionally, there was no verification of lab cultures or adherence to McGreer's criteria for infections. The facility's Infection Prevention and Control Program policy outlined procedures for tracking infections, but there was no documentation to show these procedures were followed.
Facility Lacks Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified individual to serve as the Infection Preventionist (IP) for the nursing home, which had a census of 33 residents. During an interview with the Administrator, it was revealed that the facility did not have an IP employed, and the Director of Nursing (DON) was only enrolled in a course to become certified. The DON confirmed in a separate interview that she did not possess an IP certification at the time. A review of the facility's job description for the Infection Preventionist, dated December 2024, outlined several responsibilities, including developing and implementing an infection prevention and control program, establishing systems for infection control, and overseeing the facility's antibiotic stewardship program. Additionally, the facility's policy on the Infection Prevention and Control Program, also dated December 2024, documented the program's design to provide a safe and sanitary environment to prevent the transmission of communicable diseases and infections. However, the absence of a qualified IP indicates a failure to meet these outlined responsibilities.
Deficiency in Resident Access to Personal Funds
Penalty
Summary
The facility failed to ensure that 29 out of 29 residents who relied on the facility to manage their personal finances had access to their funds as desired, including during evenings and weekends. This deficiency was identified through record reviews, resident and staff interviews, and policy reviews. The facility had a census of 33 residents at the time of the survey. Interviews with residents revealed that they did not have timely access to their personal funds. For instance, one resident reported not having access to funds on weekends, while another mentioned delays of several days in accessing money when needed. Another resident requested a $50 gift card, which had not been provided even after several days, due to the facility's limited cash supply. The facility's process for managing resident funds involved maintaining a petty cash supply of $300, which was deemed insufficient to meet the residents' needs if multiple requests were made simultaneously. The Social Services employee was responsible for managing this petty cash, but the facility's job description for the Social Services Director did not include managing resident personal funds. The Senior Revenue Cycle Manager acknowledged that if all 29 residents requested $50 on the same day, the facility would not be able to fulfill these requests due to the limited cash on hand. Additionally, requests for cash over $99 required issuing a check, which took approximately 48 hours to process, further delaying residents' access to their funds.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by several observations and staff interviews. On multiple occasions, a strong unpleasant ammonia (urine) odor was detected in the facility's west and south hallways. The Director of Nursing acknowledged that the facility should not have a urine smell. Additionally, the east hallway was observed to have a broken recliner with a brown substance, chipped paint on doors, walls, and floorboards, and broken tiles on the flooring. The east hallway shower room was found to have missing tiles, stained floor tiles with a brown substance, gaps in the shower wall that could allow water ingress, and lacked floorboards.
Failure to Verify Staff Backgrounds and Certifications
Penalty
Summary
The facility failed to ensure that background checks were completed before staff began working with residents, leading to a significant deficiency. An agency staff member worked three shifts as a Certified Nurse Aide (CNA) with a suspended certification due to abuse and one shift as a Certified Medication Aide (CMA) without verified education or certification. The staff member, identified as Staff B, was observed struggling with medication administration and lacked proper orientation. The facility's scheduler, Staff H, confirmed that no file or orientation checklist existed for Staff B, and the staffing agency had not provided necessary background checks or certification verification. Further investigation revealed that Staff B was listed as an abuser and ineligible to work in Iowa. Additionally, the Director of Nursing (DON) began working at the facility before her background check was completed. The DON worked several days without the necessary clearance, despite being instructed to stay away from residents. The facility's policy on abuse prevention and background checks was not adhered to, as evidenced by the employment of unverified staff. The facility's administrator acknowledged the lack of certification verification for another staff member, Staff K, who was scheduled but did not work due to illness.
Failure to Complete and Transmit Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete and transmit Quarterly Minimum Data Set (MDS) Assessments within federal guidelines for 9 out of 14 residents reviewed. The residents affected were identified as #4, #5, #7, #8, #9, #12, #19, #23, and #34. The assessments were not completed within the required timeframe, as they were still marked as 'In Progress' well past the 14-day completion window following the Assessment Reference Date (ARD). Additionally, many sections of the MDS for these residents were not documented as complete, indicating a significant delay in the assessment process. The Director of Nursing (DON) acknowledged the issue, stating that she was attempting to take over the MDS duties due to the absence of an MDS Coordinator. However, she was currently locked out of the system, which contributed to the delay in completing the assessments. The facility's policy, last reviewed in 2017, requires a Registered Nurse to be designated the responsibility of conducting and coordinating each resident's assessment, which was not adhered to in this instance.
Failure to Implement Restorative Program for Residents
Penalty
Summary
The facility failed to implement and maintain a Restorative Program for six residents who required assistance with their Activities of Daily Living (ADLs). The Minimum Data Set (MDS) assessments for these residents indicated varying levels of dependency on staff for tasks such as sitting to standing, transfers, bathing, dressing, and toileting. Despite these needs, none of the residents received Restorative Therapy services, and their care plans lacked documentation of any restorative nursing programs. This deficiency was identified for residents who required supervision or assistance for mobility and ADLs, highlighting a gap in the facility's provision of necessary rehabilitative services. The Director of Nursing (DON) confirmed that the facility did not have a Restorative Aide on staff and that neither the nurses nor the Certified Nurse Aides were performing any restorative programs. The facility's policy on Restorative Services, revised in October 2024, outlined the need for rehabilitative goals and objectives to be developed for each resident based on assessments. However, the facility's failure to adhere to this policy resulted in the absence of restorative programs for residents, despite their documented needs for such services.
Kitchen Sanitation and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a clean and well-maintained kitchen area for food preparation, as observed during a survey. The kitchen had a wood countertop with peeling paint due to the use of inappropriate countertop paint that reacted with chemical cleaners. Additionally, several doors and door frames had chipped and stained paint, and the corners of the floors were dirty and stained. The garbage disposal water lines had accumulated rust and dirt. Furthermore, the dishwasher's water temperature was consistently below the required 120 degrees Fahrenheit, with records showing it only reached the target temperature once in December. The issue was attributed to a new water heater not being hooked up due to the abrupt departure of the maintenance man. During lunch service, improper sanitation practices were observed. A staff member preparing pureed meals placed a utensil on a crumb-covered counter without a barrier. Another staff member, while wearing disposable gloves, touched various surfaces and then handled food without changing gloves, placing bread directly on the counter without a barrier. The Dietary Manager acknowledged these issues, including the need for reeducation on glove use and infection control, as well as the need for maintenance and cleaning of the kitchen area.
Infection Control Deficiencies in Resident Care and Facility Maintenance
Penalty
Summary
The facility failed to adhere to infection control standards during the personal care of a resident with severe cognitive impairment and a feeding tube, identified as Resident #30. The resident was dependent on staff for toileting hygiene and was always incontinent of bowel and bladder. Despite the presence of an Enhanced Barrier Precautions sign and a fully stocked isolation cart at the entrance to the resident's room, staff members were observed not using the required personal protective equipment (PPE) during high-contact care activities. Specifically, two Certified Nurse Aides (CNAs) were seen wearing only gloves while providing care, failing to use gowns as required by the facility's care plan and CDC guidelines for residents at risk of multi-drug resistant organism transmission. Additionally, the facility did not maintain proper sanitation of the ice machine, as evidenced by the lack of recent cleaning and sanitizing records. The last documented sanitization of the ice machine was nearly two months prior, and there was confusion among staff regarding responsibility for this task. Furthermore, during medication administration, a Certified Medication Aide (CMA) was observed contaminating a glass of water by placing a finger inside it while preparing oral medications for a resident. The facility also failed to implement a comprehensive water management plan to minimize the risk of Legionella and other pathogens in the building's water system. The Corporate Maintenance Manager acknowledged that the necessary checks and documentation were not being completed, and the water management forms were found incomplete. Moreover, the Director of Nursing (DON) admitted to conducting infection control audits but was unable to locate the records, indicating a lack of routine and random infection control audits to ensure compliance with infection control practices.
Failure to Implement Interventions After Resident Incident
Penalty
Summary
The facility failed to implement interventions to safeguard the dignity and wishes of Resident #34 following an incident with Resident #18. Both residents were cognitively intact, with Resident #34 experiencing delusions and having diagnoses including depression, bipolar disorder, psychotic disorder, and schizophrenia, while Resident #18 exhibited behavioral symptoms such as public sexual acts and had diagnoses of anxiety and depression. The incident occurred when Resident #18, while self-propelling his wheelchair, touched Resident #34's buttocks, which made her feel uncomfortable. Resident #18 claimed the touch was accidental and apologetic, not sexual. The facility's response to the incident was inadequate, as evidenced by the lack of immediate interventions to separate the two residents. The Director of Nursing (DON) documented the incident but failed to implement or document any measures to keep the residents apart. Witness statements from staff were collected five days after the incident, and none indicated any interventions to separate the residents. The care plans for both residents were not updated promptly to reflect necessary precautions, and staff education on the incident was limited. Interviews with staff revealed a lack of communication and direction regarding the incident. Some staff members were unaware of the incident or any instructions to keep the residents separated. The facility's policy on resident-to-resident altercations required immediate separation and documentation of interventions, which was not followed. The DON acknowledged the delay in updating care plans and stated that the facility was still within the window for submitting a five-day follow-up on the incident.
Failure to Implement Safety Interventions and Provide Supervision
Penalty
Summary
The facility failed to implement safety interventions for a resident who vapes and did not ensure appropriate supervision for a resident attending an external appointment. During an interview, the Administrator acknowledged that a resident occasionally vapes, but a review of the resident's Electronic Health Record (EHR) showed no nursing assessment regarding vaping. The Director of Nursing (DON) expected a smoking assessment to be completed and safety interventions implemented as per the facility's Accident Prevention - Smoking Policy. Additionally, another resident left the facility for a cardiologist appointment unaccompanied by facility staff, despite being unable to check in by herself. The resident's Power of Attorney (POA) found her needing assistance upon arrival. The DON stated that incompetent residents should be assisted to appointments.
Failure to Provide Adequate Notification of Financial Responsibility
Penalty
Summary
The facility failed to provide adequate notification of financial responsibility to residents and their families when Medicare Part A services were scheduled to be discontinued. This deficiency was identified for two residents. Resident #6, who had intact cognitive ability and was dependent on staff for various activities, did not have a signed CMS-10055 form in their chart, despite the facility's records indicating that an SNF ABN form was provided. Resident #34, who was independent in daily activities and undergoing therapy, also had an incomplete CMS-10055 form, lacking chosen options and a signature. The social worker acknowledged notifying the resident's Power of Attorney via email but failed to present the necessary information on the form, including daily rates and appeal options. The facility's policy, revised in August 2024, required the preparation and issuance of the SNF ABN form to residents if services were determined to potentially not be covered under Medicare. The policy also mandated documentation of the resident's understanding of their financial liability. However, the facility did not adhere to this policy, as evidenced by the missing and incomplete forms for the two residents. The social worker admitted to not obtaining the required signatures and verification of options presented, and could not account for the missing form for Resident #6, as it was before her tenure at the facility.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments within federal guidelines for three residents. Resident #24's Annual MDS, with an Assessment Reference Date (ARD) of 10/30/24, was still in progress as of 12/16/24, with twelve of eighteen sections incomplete. The last annual MDS for this resident was dated 10/30/23. Similarly, Resident #31's Annual MDS, with an ARD of 10/27/24, was also incomplete as of 12/16/24, with twelve sections unfinished. The last comprehensive MDS for this resident was the Admission MDS dated 10/27/23. Resident #34's Admission MDS, with an ARD of 8/12/24, was completed on 8/29/24, the 24th day of the resident's stay, which exceeded the required completion timeline. The facility's Director of Nursing acknowledged the delay, stating she was attempting to manage MDS duties due to the absence of an MDS Coordinator and was currently locked out of the system. The facility policy requires a Registered Nurse to be responsible for conducting and coordinating each resident's assessment.
Failure to Complete Timely MDS Assessments for Hospice Residents
Penalty
Summary
The facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments following a significant change in condition for three residents who were reviewed for MDS Assessments. Resident #6 was enrolled in hospice care on October 3, 2024, but the Significant Change MDS was not completed until October 28, 2024, which was three and a half weeks after hospice admission. Resident #7 was admitted to hospice care on November 30, 2024, but as of December 16, 2024, the MDS was still in progress with thirteen of the eighteen sections incomplete. Similarly, Resident #32 enrolled in hospice care on November 22, 2024, and as of December 16, 2024, the MDS was still in progress with twelve of the eighteen sections incomplete. According to the 2024 Resident Assessment Instrument (RAI) Manual, a Significant Change MDS is required when a terminally ill resident enrolls in a hospice program, and the Assessment Reference Date (ARD) must be no later than the 14th calendar day after the determination of a significant change in the resident's status. The Director of Nursing acknowledged the delay and stated she was trying to take over the MDS duties due to the absence of an MDS Coordinator, but was currently locked out of the system. The facility's policy requires a Registered Nurse to be designated the responsibility of conducting and coordinating each resident's assessment.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to complete and transmit Minimum Data Set (MDS) Assessments within federal guidelines for two residents. Resident #26 was discharged from the facility on 10/22/24, but as of 12/16/24, the Discharge MDS was still marked as In Progress, with nine of fifteen sections incomplete. Resident #32 had a quarterly MDS with an Assessment Reference Date (ARD) of 10/20/24, and although it was completed by 11/22/24, it had not been transmitted to CMS by 12/16/24. According to the 2024 Resident Assessment Instrument (RAI) Manual, a discharge assessment must be completed within 14 days of discharge, and a quarterly assessment must be transmitted within 14 days of completion. The Director of Nursing stated she is attempting to manage MDS duties due to the absence of an MDS Coordinator and is currently locked out of the system, which has contributed to the delay.
Failure to Include Diabetes Management in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident diagnosed with diabetes and heart failure, who was receiving insulin injections. The Minimum Data Set (MDS) Assessment for the resident documented the administration of insulin over a seven-day period, yet the resident's care plan did not include the diagnosis of diabetes or the orders for insulin. This oversight was identified during a review of the resident's clinical records, which revealed active orders for Insulin Glargine and Humalog Insulin, both of which were absent from the care plan. The facility's policy on comprehensive care plans, revised in August 2022, mandates that care plans should be individualized and include measurable objectives and time frames to address the resident's medical, nursing, mental, cultural, and psychological needs. The policy also requires that care plans be based on thorough assessments, including the MDS and physician orders, and be revised as the resident's condition changes. The failure to include the resident's diabetes diagnosis and insulin orders in the care plan was contrary to these guidelines, as confirmed by the facility's President of Operations.
Failure to Revise Care Plan for Resident Who Vapes
Penalty
Summary
The facility failed to review and revise the care plan for a resident who occasionally vapes, as identified during a survey. The resident's care plan lacked specific instructions and directions regarding vaping, which was confirmed during an interview with the Administrator. The Director of Nursing expressed that the care plan should have included information about the resident's vaping habits along with appropriate safety interventions. The facility's Accident Prevention - Smoking Policy, effective August 2024, required residents who wish to smoke to be evaluated for safe smoking per community protocol, but it did not include instructions for incorporating this into the resident's care plan. Additionally, the facility's Comprehensive Care Plans policy, also effective August 2024, outlined requirements for care plans to incorporate identified problem areas and risk factors, but this was not reflected in the resident's care plan regarding vaping.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a Gradual Dose Reduction (GDR) was attempted yearly for a resident on an antipsychotic medication. The resident, who was admitted to the facility and had a documented severe cognitive impairment, was receiving Seroquel daily. Despite the facility's policy requiring routine monitoring and consideration of GDR for residents on antipsychotic medications, no attempt at GDR was made for this resident. The resident's care plan included monitoring for psychotropic drug-related problems and consulting with pharmacy and the doctor for dosage reductions when appropriate. A review of the resident's progress notes indicated that a telemedicine psychiatric consultation advised against a GDR at that time to prevent decompensation. The facility's policy on tapering medications and GDR, last revised in September 2022, allows for GDR to be considered contraindicated if continued use is in accordance with current standards of practice and documented by the physician. However, the facility did not document any such rationale for not attempting a GDR for this resident, leading to the deficiency noted in the report.
Failure in Narcotic Documentation and Destruction
Penalty
Summary
The facility failed to accurately document narcotic medication use and did not destroy narcotic medication after discontinuation for two residents. For Resident #6, the facility did not destroy a discontinued PRN package of Tramadol, which remained in the narcotics storage drawer. The Controlled Medication Utilization Record (CMUR) showed discrepancies in the documentation of Tramadol administration, with inconsistencies between the CMUR and the Medication Administration Record (MAR). This indicates a failure in proper documentation and medication management. For Resident #20, the facility retained expired orders of Ativan in the narcotic drawer, despite the resident being on hospice care and no longer swallowing pills. The CMUR indicated that a tab was given on a specific date, but the Director of Nursing acknowledged that the medications should have been destroyed as per facility policy. This oversight in medication management and documentation reflects a lapse in following established procedures for handling discontinued narcotics.
Failure to Provide Therapeutic Meals as Ordered
Penalty
Summary
The facility failed to provide therapeutic meals as ordered for three residents with altered diets. Resident #30, who had severe cognitive deficits and was dependent on staff for daily activities, was on a pureed diet but was served breakfast with visible chunks of green peppers, which did not comply with the pureed texture requirement. Resident #22, also with severe cognitive deficits and requiring assistance with eating, was on a mechanically altered diet due to dysphagia but was served crispy garlic toast, which was inappropriate for her dietary needs. Similarly, Resident #3, with moderate cognitive deficits and on a mechanically altered diet, was also served crispy garlic toast, contrary to his dietary orders. The deficiency was further compounded by the staff's lack of understanding of the International Dysphagia Diet Standardization Initiative (IDDSI) codes, which led to confusion about the appropriate diet textures. The cooks, Staff C and Staff D, admitted to not understanding the acronyms used in the diet texture columns, which resulted in incorrect meal preparation. The Dietician acknowledged the complexity of the IDDSI codes and expressed concern over the inappropriate food textures served to the residents. The Dietary Manager also expressed frustration with the IDDSI menus and the challenge of educating staff on the correct foods for mechanically altered diets.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to provide a pneumococcal vaccine to a resident who had consented to receive it. The resident, who had an intact cognitive ability with a BIMS score of 15, was independent in daily activities and was undergoing radiation/chemotherapy for breast cancer. The resident's Power of Attorney had signed an informed consent for the pneumococcal vaccine on 9/11/24. However, the vaccine was not administered, and the Director of Nursing, who was not present at the facility in September, was unaware of the reason for this oversight. The facility's policy, revised in 10/2024, stated that residents would be offered the pneumococcal vaccine unless medically contraindicated or previously vaccinated, but this was not followed in this case.
Failure to Administer COVID-19 Booster to Residents
Penalty
Summary
The facility failed to provide the COVID-19 immunization booster to two residents who had signed consent agreements for the vaccine. Resident #20, who had a history of chronic kidney disease, heart failure, and a previous COVID-19 infection, was dependent on staff for various activities of daily living and had a care plan indicating a risk for injury due to impaired safety awareness. Despite having a consent form dated 5/13/24, there was no evidence that the booster was administered. Similarly, Resident #30, who had severe cognitive deficits and was dependent on staff for all activities of daily living, also had a consent form signed by a Power of Attorney on the same date, but the immunization tab in the electronic chart lacked documentation of the COVID-19 booster. The interim Director of Nursing acknowledged the oversight, noting that there was no evidence that the COVID-19 booster had been offered to residents, and the facility's policy stated that vaccinations would be offered per CDC and CMS guidelines. The policy indicated that the community would offer the COVID-19 vaccination when available, but the resident files showed that the booster had not been administered in 2023 or 2024. This failure to follow through on the vaccination process led to the deficiency noted in the report.
Failure to Complete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine the necessary resources for competent resident care during both regular operations and emergencies. The Director of Nursing (DON) identified on November 22, 2024, that the facility did not have a facility assessment in place. Despite recognizing this deficiency, the assessment was not completed by the time of the survey. The DON indicated that the assessment was planned to be completed by December 31, 2024, but as of December 12, 2024, it remained incomplete. The facility had a census of 33 residents at the time of the survey.
Failure to Implement QAPI Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through record review, staff interviews, and policy review. The Director of Nursing (DON), who started her position in November 2024, acknowledged that the facility did not have a QAPI program in place. A document titled Self-Identification Form and Correction Form, dated December 10, 2024, revealed that the DON identified the absence of a QAPI program on November 22, 2024, and planned to begin monthly meetings starting January 7, 2024. Despite having a large binder with a QAPI plan, no one was actively completing it at the time of the survey.
Lack of QAPI Program Implementation
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) program was not implemented, leading to a lack of monitoring of adverse events, systematic analysis, systemic actions, program activities, and quality assessment and assurance. The Director of Nursing (DON), who started her position in November 2024, identified on 11/22/24 that the facility did not have a QAPI program in place. A document titled Self-Identification Form and Correction Form dated 12/10/24 revealed this deficiency. During an interview on 12/12/24, the DON confirmed that although she had a large binder with a QAPI plan, no one was completing it at the time. The facility reported a census of 33 residents.
Failure to Ensure Professional Interaction with Resident
Penalty
Summary
The facility failed to ensure staff interacted with residents in a professional manner, specifically concerning a resident with severe cognitive impairment and multiple diagnoses, including stroke, hemiplegia, diabetes, depression, schizophrenia, and respiratory failure. The incident involved a verbal altercation between the resident and a Certified Nursing Assistant (CNA), identified as Staff A. The resident, who had a history of delusional behaviors, alleged verbal abuse by Staff A, which included the use of profanity. The resident expressed a preference for another staff member, Staff B, and did not want Staff A's assistance. During the incident, the resident reportedly used profanity towards Staff A, who then allegedly responded with profanity as she left the room. Interviews with staff members provided conflicting accounts of the incident. Staff A denied using profanity, while Staff B and Staff C reported hearing or being informed of Staff A's use of profanity towards the resident. Staff B witnessed the resident crying after the incident and noted that the resident was not herself for the rest of the night. The facility's policy on resident rights emphasizes treating residents with dignity and respect, which was not upheld in this situation, leading to the deficiency finding.
Failure to Follow Antibiotic Stewardship Program
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program by not following antibiotic use protocols and failing to monitor antibiotic use for a resident diagnosed with cerebral palsy, seizure disorder, anxiety, and depression. The resident, who had intact cognition and was independent in toileting hygiene, experienced urinary frequency and was prescribed the antibiotic Cipro. However, the facility did not report to the physician that the antibiotic was resistant to the microorganism Proteus mirabilis identified in the urine culture. This oversight occurred twice, as the resident was again prescribed Cipro despite the resistance noted in the culture and sensitivity lab reports. The facility's progress notes and interviews with staff revealed that the resident had become incontinent and was experiencing urinary frequency, which was not documented in the care plan. The physician confirmed that he was not informed of the antibiotic resistance, which would have prompted a change in medication. The facility's policy on antibiotic stewardship emphasized the importance of monitoring antibiotic use and resistance patterns, but these protocols were not followed, leading to the deficiency.
Inadequate Staffing Leads to Missed Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of its residents, resulting in missed or delayed care. Multiple residents with intact cognition reported significant delays in response to call lights and unmet personal care needs, such as bathing. Resident #1 expressed concerns about long wait times for call lights, while Resident #2 and Resident #3 reported not receiving showers as scheduled, with documentation confirming no showers or baths were recorded for a month. Staff interviews corroborated these issues, with reports of insufficient staffing levels due to call-ins and financial constraints limiting the use of agency staff. The facility's staffing records indicated low staffing numbers on several dates, and interviews with staff, including CNAs, LPNs, and former and current DONs, highlighted ongoing staffing challenges. The Administrator acknowledged concerns about staffing and the impact on resident care, particularly regarding showers and baths. Financial difficulties with staffing agencies and a negative reputation further exacerbated the staffing shortages, leading to inadequate care for residents.
Failure to Report Abuse and Misappropriation of Funds
Penalty
Summary
The facility failed to protect residents from abuse by not ensuring that all allegations of abuse were reported and investigated in a timely manner. An allegation was made that a staff member was taking a resident to her home, which was deemed inappropriate. Despite the allegation being reported to the Administrator and the previous Director of Nursing (DON) via email, no action was taken for the first week. The Administrator confirmed receiving the email but did not report the incident to the State Entity until several weeks later. Additionally, the facility did not implement interventions to protect residents from potential misappropriation of funds. A staff member was found to have held a resident's funds at their home, which violated the facility's policy. The staff member returned the money only after being instructed by the Administrator and the acting DON. Furthermore, the facility failed to implement a plan of correction for deficiencies cited during a previous complaint investigation. The acting DON was unaware of the plan and could not locate any documentation of education or audits that were supposed to be completed as part of the corrective measures.
Pest Infestation in Facility
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by multiple reports of mice infestations. Several residents reported seeing mice in their rooms and common areas, with one resident noting that mice had eaten food stored in their drawer. Observations confirmed the presence of holes in the bathroom and mice droppings in various locations, including the Social Services office. Despite the facility's efforts to place sticky traps and use steel wool to block entry points, the issue persisted, indicating an ongoing problem with pest control. Interviews with staff and pest control technicians revealed inconsistencies in the pest control program. The Maintenance Supervisor and pest control technicians provided conflicting accounts of the frequency and effectiveness of pest control measures. While the pest control company reportedly visited monthly, there was a lack of communication and follow-up on recommendations to address the infestation. The facility's policy on pest control, dated 2016, emphasized the importance of immediate reporting and action, but the implementation appeared inadequate. The Administrator acknowledged the pest issue and mentioned efforts to mitigate it, such as setting traps and advising residents to store food properly. However, there was no evidence of a comprehensive plan to seal entry points or address the root causes of the infestation. The facility's reliance on temporary measures like sticky traps and sporadic pest control visits failed to resolve the problem, leading to continued reports of mice sightings and droppings throughout the building.
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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