Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Azria Health Longview during CMS and state inspections, most recent first.
A facility failed to protect residents from exploitation involving controlled substances. An oxycodone cubie in the med bank was found tampered with, with oxycodone packets altered and replaced with carvedilol, and an LPN was linked to repeated access and an unexplained removal of oxycodone for a resident with significant chronic pain. The resident had a BIMS score of 14 and was receiving PRN opioid pain medication, but the medication removed from the med bank was not clearly documented as administered.
The facility failed to maintain a comprehensive, effective QAPI program after repeat deficiencies were identified in survey and complaint investigations, including QAPI plan and exploitation. The Administrator stated staff are educated on process changes after deficiencies are found, the same information is reviewed in huddles, and audits are completed for about 3 months or until compliance is reached. The facility's QAPI policy, revised in February 2020, described a committee-led process for tracking performance, identifying deficiencies, analyzing causes, implementing corrective actions, and monitoring effectiveness.
A resident, assessed as cognitively intact but with a care plan noting risk for impaired thought processes, gave a CNA money on two occasions after the CNA discussed personal financial and domestic issues. The CNA was observed in the resident's room with the resident's wallet, and the resident later confirmed giving the CNA a total of $112. The CNA denied the transactions, but facility records and interviews supported the resident's account. Facility policy prohibits staff from accepting money from residents, and the CNA had acknowledged this policy.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during the inspection.
The facility did not complete required self-administration assessments for two residents who were found with medications at their bedside and self-administering them, contrary to facility policy. Additionally, a resident with severe cognitive impairment and a history of falls experienced a fall resulting in a hip fracture, but staff did not consistently assess, document, or communicate changes in pain and bruising, nor did they promptly obtain an x-ray as directed by the physician.
The facility was cited for failing to implement an effective QAPI program, resulting in repeat deficiencies related to pressure ulcer prevention and infection control. The Administrator confirmed that Enhanced Barrier Precautions were not discussed in Quality Assurance meetings, and ongoing challenges with pressure ulcer management persisted, despite facility policy requiring regular review and improvement activities.
Staff failed to consistently use Enhanced Barrier Precautions (EBP) and universal infection control measures for several residents with wounds, indwelling catheters, and multidrug-resistant organisms. Observations showed staff did not always perform hand hygiene between glove changes, did not use gowns as required, and sometimes used improper techniques during wound and peri care, despite facility policies and staff awareness of the requirements.
Multiple residents with complex medical needs experienced significant delays in call light response, with documented wait times often exceeding 15 minutes and sometimes reaching up to 45 minutes. Staff interviews and call light logs confirmed that the facility did not consistently meet its policy of timely response, resulting in residents waiting for essential assistance such as toileting and being put to bed.
Two residents did not receive care according to physician orders, including missed medication administration for a newly admitted resident and inconsistent wound care for another resident with a chronic ulcer. Staff failed to notify the physician of missed medications, delayed pharmacy communication, and did not consistently apply wound dressings or compression stockings as ordered, resulting in increased edema and wound deterioration.
A resident with physical impairments and no cognitive deficits waited over 15 minutes for toileting assistance after activating the call light. Staff acknowledged the request but failed to respond promptly, resulting in the resident experiencing incontinence and feelings of embarrassment and loss of dignity. Staff interviews confirmed the delay exceeded facility expectations for call light response.
A resident with multiple diagnoses, including cancer and diabetes, was receiving daily Furosemide as ordered by a physician, but the care plan did not document the use of this high-risk medication. The DON confirmed that diuretic use should have been included in the care plan, and facility policy requires care plans to be updated as resident conditions change.
A resident with multiple medical conditions and intact cognition was not assessed for smoking safety, and their care plan did not address smoking, despite facility policy requiring such assessments. Staff provided cigarettes and assisted the resident with smoking without a documented evaluation of the resident's ability to smoke safely.
A resident with end-stage renal disease and dependent on dialysis did not have required post-dialysis assessments completed and documented on multiple occasions, despite physician orders and facility policy. Nursing staff and the DON confirmed that these assessments were expected on each dialysis day, but several dates were identified where documentation was missing.
Three residents with cognitive deficits and swallowing difficulties were served regular corn instead of the scheduled vegetable, despite being on mechanical soft diets. The dietary aide was unaware that regular corn was not suitable for these diets, and a delay in updating diet orders further contributed to the deficiency. The facility's policy requiring physician-specified therapeutic diets was not consistently followed.
A resident with significant mobility needs developed a pressure ulcer on the right heel that progressed from a bruise to an open wound and then to a stage 3 ulcer. Facility staff did not apply any treatment or dressing to the wound for eight days, despite recognizing the change in condition, and failed to notify the primary provider or obtain wound care orders until the visiting wound care nurse assessed the wound. Communication lapses and lack of adherence to wound care policy contributed to the delay in care.
The facility experienced delays in responding to resident call lights, with some residents waiting up to an hour for assistance. Observations and resident complaints highlighted extended wait times, often due to staffing shortages. Staff interviews confirmed that call light responses could exceed 15 minutes when understaffed, despite the facility's policy emphasizing timely responses.
The facility failed to complete physician's orders for two residents, leading to deficiencies in care. A resident with no cognitive impairment did not receive a timely strep test, while another with severe cognitive impairment had delayed wound care and consults. The DON was on vacation, and there was inadequate follow-up by the ADON, resulting in missed and delayed orders.
The facility failed to provide adequate incontinence care for three residents dependent on staff for ADLs. A resident was left in soiled clothing overnight, another indicated inconsistent bedding changes, and a third reported delays in being cleaned up. Staff interviews confirmed residents were often found soaked after the overnight shift, highlighting a pattern of neglect in timely care.
The facility failed to prevent and properly treat pressure ulcers for two residents. One resident developed a heel ulcer that worsened due to delayed treatment and inconsistent use of Prevalon boots, leading to hospitalization. Another resident with a chronic pressure area did not receive the recommended barrier creams after incontinence episodes, contrary to the care plan. These deficiencies highlight the facility's failure to adhere to care plans and physician orders, resulting in the deterioration of residents' conditions.
A facility failed to follow physician orders and provide timely incontinence care for two residents. One resident, with a UTI and septicemia, experienced delays in diagnosis and treatment due to inadequate communication and order execution. Another resident, dependent on staff for toileting, was found with soaked protective pads and soiled shorts, indicating a lack of timely care. The facility's policy required regular toileting assistance, which was not consistently provided.
The facility failed to serve food at appropriate temperatures to several residents, as reported by residents and confirmed by temperature checks. A resident stated that food was often cold, and another mentioned that the kitchen manager did not address complaints. Temperature checks showed food below expected temperatures, and staff interviews indicated delays in food delivery. The facility's policy required maintaining proper food temperatures, which was not followed.
The facility failed to follow proper sanitation and food handling practices, as staff members did not adhere to hand hygiene protocols and served food without appropriate coverings. Staff with facial hair did not wear required coverings, and ice was added to beverages using glasses instead of scoops, contrary to facility policies.
A facility failed to update the PASRR for a resident diagnosed with new mental health disorders, including anxiety, depression, and PTSD. Despite these diagnoses, the PASRR was not revised, and the oversight was acknowledged by staff during interviews. The facility lacked a policy for updating PASRRs when residents received new mental health diagnoses.
A facility failed to maintain accurate medical records for a resident on enteral feeding, as several instances of unsigned MARs were found. The resident reported occasional delays in starting feedings, which were confirmed by staff interviews. Despite these delays, the resident did not miss any feedings. The facility's policy required documentation of medication administration, which was not consistently followed.
The facility failed to provide adequate hand hygiene and Enhanced Barrier Precautions (EBP) for three residents. A resident with intact cognitive ability did not receive proper glove changes during incontinence care. Another resident with renal issues and a permacath did not have PPE used during a post-dialysis assessment. A third resident with an indwelling catheter did not have a gown applied during catheter care. Facility policies and CDC guidelines were not followed.
A resident reported missing money to staff, but the grievance was not documented or resolved for several months. The facility's grievance policy was not followed, leading to a failure to address the resident's concerns promptly.
Controlled Substance Diversion and Unexplained Oxycodone Handling
Penalty
Summary
The facility failed to ensure residents were free from exploitation involving controlled substances and resident belongings/money. The deficiency centered on a narcotic diversion investigation involving oxycodone stored in the facility’s med bank and on the handling of a resident’s PRN oxycodone. Resident #1 had multiple pain-related diagnoses, including lumbosacral fusion, chronic low back pain, rheumatoid arthritis, right shoulder osteoarthritis, anxiety, depression, seizure disorder, and chronic myeloid leukemia. His MDS showed a BIMS score of 14, indicating no cognitive impairment, and documented near-constant pain that affected sleep, therapy, and daily activities. Review of the MARs and narcotic records showed Resident #1 had oxycodone orders and doses documented from the medication cart and the med bank. The investigation found that Staff A accessed the med bank at 2:43 AM and removed two oxycodone 5 mg tablets for Resident #1, even though the resident’s next dose was not due until later that morning and there was no documentation that the medication was administered. The facility also found that the oxycodone pulled from the med bank was not signed out on the MAR or narcotic record in a manner consistent with the resident’s medication administration, and staff gave conflicting accounts about whether the medication was to be documented and whether it was placed in a cup in the medication cart for later use. The facility’s investigative file further documented that the oxycodone 5 mg cubie in the med bank had been tampered with. Pharmacy staff reported the cubie appeared broken and resealed with adhesive, and the medication packets inside had been altered: 13 packets were present, one empty and 12 containing carvedilol instead of oxycodone. Staff interviews described repeated access to the med bank drawer and fridge key, concerns about the cubie not opening, and observations that Staff A had accessed the med bank during overnight shifts. The investigation also included reports of suspicious behavior by Staff A and a drug screen process that was not completed as requested.
QAPI Program Not Comprehensive or Effective
Penalty
Summary
The facility failed to ensure it had a comprehensive, effective QAPI program. A review of the Department of Inspections, Appeals, and Licensing website showed repeat deficient practices during the annual survey and complaint investigations from 2/27/2024 through 10/1/2025, including a repeat deficiency cited on 6/12/2025 for QAPI plan and on 10/1/2025 for exploitation. The facility had a census of 80 residents. During an interview on 11/25/2025 at 12:17 PM, the Administrator stated that after deficiencies are identified, staff are educated on the process change before their next working shift and the same information is brought to huddle meetings. When asked how the facility ensures the issue has been resolved, she stated audits are completed for about three months or until compliance is achieved. Regarding the repeated exploitation deficiency, she stated she felt both issues were ethical issues with staff and that the facility's processes were in place and worked successfully, but staff involved took advantage of the situation. The facility's QAPI policy, revised in February 2020, stated the QAPI committee oversees implementation of the QAPI plan, which describes how the facility conducts QAPI functions and includes tracking and measuring performance, establishing goals and thresholds, identifying and prioritizing deficiencies, analyzing underlying causes, developing corrective actions, and monitoring effectiveness.
Failure to Prevent Financial Exploitation of a Resident by Facility Staff
Penalty
Summary
A resident with a history of anemia, renal failure, bipolar disorder, respiratory failure, and a stage 3 sacral pressure ulcer, and who was assessed as cognitively intact with a BIMS score of 15, was involved in multiple financial transactions with a Certified Nursing Assistant (CNA) employed by the facility. The resident's care plan noted a risk for impaired cognitive function or thought processes, but the resident was his own payee and managed his own finances. The CNA was observed in the resident's room while the resident had his wallet out, and subsequent interviews revealed that the resident had given the CNA money on two separate occasions. The first incident occurred when the CNA complained to the resident about personal financial difficulties, specifically needing to fix her car battery. The resident gave the CNA $100, expecting repayment. The CNA later attempted to repay a portion of the money, but the resident declined partial repayment, requesting the full amount instead. On a subsequent occasion, the CNA informed the resident of a domestic situation, and the resident gave her an additional $12. The resident did not initially report these transactions, stating he willingly lent the money and would consider it a loss if not repaid. Facility staff became aware of the situation when the Assistant Administrator observed the CNA with the resident and his wallet. Upon inquiry, the resident confirmed giving money to the CNA. The CNA denied accepting any money from the resident. The facility's review of timecards indicated the CNA was not scheduled to work on the days the transactions occurred, but she had been present in the facility. The facility's policies prohibit staff from accepting money from residents, and the CNA had signed documents acknowledging these policies. The events were reported to local authorities, but no criminal charges were filed as the resident was deemed to have willingly given the money.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Complete Required Assessments and Medication Self-Administration Reviews
Penalty
Summary
The facility failed to complete required assessments and follow professional standards of practice for three residents. Two residents, both with no cognitive impairment and physician orders for self-administered medications (albuterol inhalers and topical powder), were observed to have these medications at their bedside and reported self-administering them. However, there was no documentation of a medication self-administration assessment or a care plan addressing self-administration for either resident. The DON confirmed that no assessments had been completed and acknowledged that medications should not have been left in the residents' rooms without such assessments, as required by facility policy. Another resident with severe cognitive impairment and a history of falls experienced a witnessed and an unwitnessed fall, the latter resulting in a left hip fracture. After the unwitnessed fall, the resident initially complained of pain, but this was not consistently documented or communicated among staff. Although the physician was notified and indicated that an x-ray should be obtained if needed, this instruction was not documented in the written shift exchange, and subsequent staff were unaware of it. The resident continued to have pain and increased bruising, which was reported to nurses but not fully assessed or documented. An x-ray confirming the fracture was not obtained until several days later, after ongoing pain and functional decline were noted. Facility policy required ongoing assessment and documentation for 72 hours after a fall, including monitoring for changes in pain, mobility, swelling, and bruising. The staff did not consistently follow this policy, as changes in the resident's condition and new bruising were not fully assessed or investigated. The DON and Administrator acknowledged that changes in pain and new bruising should have prompted further assessment and communication with the physician, and that the transition to hospice care should not have altered the standard of care provided.
Repeat Deficiencies in QAPI, Pressure Ulcer Prevention, and Infection Control
Penalty
Summary
The facility failed to provide a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies in the areas of pressure ulcer prevention and treatment, and infection control. The facility had a census of 86 residents and had previously been cited for these same issues during annual surveys and complaint investigations. The Administrator acknowledged that Enhanced Barrier Precautions (EBP) had not been reviewed or addressed in Quality Assurance meetings, and that pressure ulcer prevention and treatment remained an ongoing challenge. Facility policy required a data-driven, facility-wide QAPI program with monthly committee meetings to review reports and make adjustments, but these processes were not effectively implemented or followed, as indicated by the repeat deficiencies.
Failure to Implement Enhanced Barrier Precautions and Infection Control Measures
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) for multiple residents with conditions requiring such precautions. For a resident with renal insufficiency, a multidrug-resistant organism (MDR), and wounds, staff did not change gloves or perform hand hygiene between tasks and failed to wear gowns as required by EBP during repositioning and wound care. Similarly, another resident with an indwelling catheter and positive MRSA status was transferred and repositioned by staff who did not change gloves or perform hand hygiene, and did not wear gowns as required. Staff interviews confirmed awareness of the need for gowns and proper hand hygiene, but these practices were not followed during observed care. In another case, a resident with a chronic vascular ulcer and EBP orders for wounds received wound care from an LPN who inconsistently performed hand hygiene between glove changes and used paper towels instead of a chuck pad as a barrier for dressing supplies. The LPN also used sanitized scissors to cut through dressing packaging, which was not in line with facility expectations. The resident reported that only certain staff wore gowns during treatments, and interviews with staff revealed confusion about EBP signage and inconsistent use of PPE prior to the current week. A further deficiency was observed with a resident who had a stage 4 pressure ulcer and was on EBP for wounds. During wound and peri care, an RN did not consistently perform hand hygiene between glove changes, used improper techniques for cleansing and ointment application, and required reminders from another staff member to use a gown and perform hand hygiene. Facility policy and staff interviews confirmed that hand hygiene should be performed after glove removal and between tasks, and that PPE should be used as indicated by EBP orders, but these protocols were not consistently followed during the observed care.
Failure to Provide Timely Response to Resident Call Lights
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to resident call lights, resulting in delays for multiple residents. Observations, interviews, and call light log reviews revealed that several residents experienced wait times exceeding 15 minutes on numerous occasions when requesting assistance. For example, one resident with diabetes, end stage renal disease, and vascular dementia reported that it often took longer than 15 minutes for staff to respond to her call light, with documented instances of response times ranging from 16 to 45 minutes over several days. The resident also stated that staff told her they did not have time to assist her with being put to bed. Another resident with hemiplegia, muscle weakness, and anxiety disorder was observed waiting over 15 minutes for assistance to use the toilet, despite staff being aware of her need. The call light log for this resident also showed multiple instances of delayed responses, some exceeding 40 minutes. Staff interviews confirmed that the facility's expectation was to answer call lights within 15 minutes, but acknowledged that this standard was not consistently met. The DON and Administrator both stated that call lights should be answered as soon as possible, and that grievances regarding call light response times had been received. Additional residents reported similar experiences, including one who had to wait 45 minutes on the toilet during a shift change and another who stated that call lights frequently took over 15 minutes to be answered. The facility's policy requires staff to answer call lights in a timely manner, but the documented delays and resident reports indicate that this policy was not consistently followed, resulting in unmet care needs for several residents.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents, specifically by not following physician orders for medication administration and wound care. One resident was admitted with multiple diagnoses, including heart failure, renal insufficiency, diabetes, anxiety disorder, and respiratory failure. Upon admission, the resident did not receive any of the prescribed evening medications, and there was no documentation that the physician was notified of the missed doses. The medication orders were not faxed to the pharmacy until later in the evening, resulting in a delay in medication delivery. The resident and a family member reported that medications were not administered and that the resident's oxygen tank ran out without timely replacement, prompting the resident to leave the facility against medical advice the following day. Another resident with a history of coronary artery disease, heart failure, and peripheral vascular disease had a care plan addressing the risk for pressure ulcer development and a chronic vascular ulcer on the right lower leg. The facility staff did not consistently follow wound care orders as written by the resident's provider, including the application of dressings and compression stockings. Observations and staff interviews revealed that wound care treatments were missed or performed incorrectly, with staff citing time constraints and lack of specific training. Documentation showed that the resident experienced increased edema, wound deterioration, and episodes of cellulitis, with inconsistent use of compression stockings and incorrect dressing applications. Multiple progress notes and interviews with external care providers indicated ongoing concerns about the facility's compliance with wound care orders. The facility's own policies required that physician orders be followed and that the DON or designee and physician be notified if orders could not be carried out. Despite this, there were repeated failures to adhere to prescribed treatments, and the DON and administrator acknowledged missed treatments and lack of staff education. The deficiencies were substantiated by clinical record reviews, resident and family interviews, pharmacy and staff interviews, and policy review.
Failure to Provide Timely Toileting Assistance Compromising Resident Dignity
Penalty
Summary
A deficiency occurred when staff failed to provide timely toileting assistance to a resident with no cognitive impairment, as indicated by a BIMS score of 15, and diagnoses including hemiplegia, hemiparesis, anxiety disorder, and generalized muscle weakness. The resident, who required assistance with personal care, activated her call light to request help with toileting. Staff entered the room, acknowledged her request, and stated they would return to assist her, but the call light was turned off and the resident was left waiting for more than 15 minutes. During this period, staff communicated the resident's need to other staff members, but no one responded promptly to her request. The resident reported that it frequently took longer than 15 minutes for staff to answer her call light, and on this occasion, she waited approximately 30 minutes before receiving assistance, resulting in incontinence. The resident expressed feelings of embarrassment, shame, sadness, and a lack of dignity due to the delay and subsequent incontinence. Staff interviews confirmed the delay exceeded the facility's expectation for call light response times, and the facility's policy emphasized the importance of prompt response to promote resident dignity and well-being.
Failure to Include Diuretic Use in Comprehensive Care Plan
Penalty
Summary
The facility failed to provide a comprehensive care plan addressing the use of high-risk medications for one resident who had a physician's order for daily diuretic therapy. Clinical document review showed that the resident had diagnoses including cancer, diabetes mellitus, and hyperlipidemia, and was receiving Furosemide 20 mg daily. However, the resident's care plan, last revised on 5/21/25, did not include any documentation regarding the use of diuretics. Staff interview with the DON confirmed that diuretic use should have been included in the care plan. Facility policy requires ongoing assessment and revision of care plans as resident conditions change, but this was not followed for the resident in question.
Failure to Assess Resident for Smoking Safety
Penalty
Summary
The facility failed to assess a resident for safety while smoking, as required by their own policy. Clinical record review showed that the resident, who had intact cognition and multiple diagnoses including hypertension, peripheral vascular disease, renal failure, respiratory failure, and an above-the-knee amputation, used tobacco products. Despite this, there was no documentation of a smoking assessment in the resident's electronic health record, nor was smoking addressed in the resident's care plan. Progress notes indicated that the resident requested cigarettes and a lighter for an appointment, and staff reviewed the smoking policy with the resident, but no formal assessment was completed. Observation revealed that staff provided cigarettes and a lighter to the resident and assisted with lighting and disposing of cigarettes during a smoking period. Interviews with the DON and Administrator confirmed that a smoking assessment should have been completed and included in the care plan, in accordance with facility policy, which requires evaluation of smoking status on admission and routine re-evaluation of the ability to smoke safely. The lack of assessment and care planning for smoking safety constituted the deficiency.
Failure to Complete Post-Dialysis Assessments for Resident Receiving Dialysis
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards by not completing post-dialysis assessments for a resident who required such care. Review of the electronic health records (EHR) for a resident with end-stage renal disease and dependence on renal dialysis revealed multiple instances over a 60-day period where post-dialysis assessments were not documented, despite physician orders requiring complete pre- and post-dialysis vital signs, weight, and evaluation. The resident was cognitively intact and attended dialysis three times weekly as scheduled. Interviews with nursing staff, including LPNs, an RN, and the Director of Nursing (DON), confirmed that pre- and post-dialysis assessments were expected to be completed and documented on each dialysis day. The DON acknowledged that the identified dates lacked the required post-dialysis assessments and stated that her expectation was for these assessments to be completed and charted in the appropriate sections of the EHR. Facility policy also required staff to be educated and trained on the specific assessment data to be gathered for residents receiving dialysis.
Failure to Provide Appropriate Mechanically Altered Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents requiring mechanically altered diets. During a lunch service, the dietary staff ran out of the scheduled vegetable, broccoli, and substituted corn for residents on mechanical soft diets. The dietary aide/cook was not aware that regular corn is not suitable for mechanically soft diets, and served it to three residents with orders for mechanical soft diets. The dietician later confirmed that only creamed corn would be acceptable for such diets, not regular corn. The residents affected included individuals with severe to moderate cognitive deficits, swallowing difficulties, and risks for nutritional deficits. Their care plans and physician orders specified the need for mechanical soft diets due to conditions such as dysphagia and Alzheimer's disease. Additionally, there was a delay in updating dietary orders following a change in one resident's diet texture, as communication from speech therapy to nursing was not transcribed in a timely manner. The facility's policy required that therapeutic diets be prescribed and specified by the attending physician, but this was not consistently followed.
Failure to Provide Timely Pressure Ulcer Treatment and Prevention
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and adequate treatment and interventions to prevent the worsening of a pressure ulcer for one resident. The resident, who required significant assistance with mobility and transfers, developed an open area on the right heel that was initially identified as a bruise. Over time, the area progressed to a stage 2 pressure ulcer, and later to a stage 3 ulcer with necrotic tissue and slough. Despite the change in the wound's condition, no treatment or dressing was applied to the right heel for eight days, from the time the area became open until the visiting wound care nurse assessed the wound and initiated treatment orders. Documentation and interviews revealed that the facility staff recognized the change in the wound on the right heel, including the presence of a blister, crack, and drainage. The Director of Nursing (DON) and other staff acknowledged that the area was not just a bruise but had become an open wound. However, there was no evidence that the primary physician was notified or that a request for wound treatment was made during this period. The wound care nurse, upon arrival, noted that the wound was unstageable due to eschar and slough, and expressed concern that no dressing or treatment had been started prior to her visit. The resident was observed resting the affected heel on the bed frame without protective boots, further contributing to the pressure and injury. The facility's own policies required physician notification and wound care orders for abnormalities such as wounds, but these steps were not followed. Communication lapses between facility staff and providers contributed to the delay in care, as the resident's primary provider was not informed of the wound's progression. Staff interviews confirmed that no dressing or treatment was applied to the open area until the wound care nurse's assessment, despite the wound being at least a stage 2 ulcer at the time it became open.
Delayed Call Light Responses Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple observations and resident complaints. On specific occasions, call lights were activated for extended periods, such as 23 and 22 minutes, before being addressed by staff. Resident council notes and grievance logs consistently documented concerns about delayed call light responses over several months, with residents expressing dissatisfaction with the time it took for staff to respond. Interviews with residents revealed that some experienced wait times of up to an hour, leading to incidents such as accidents due to delayed assistance. Staff interviews indicated that staffing shortages contributed to the delays in responding to call lights, with CNAs acknowledging that response times could exceed 15 minutes when the facility was understaffed. The facility's administrator and Director of Nursing were aware of the issue, with the administrator noting the lack of means to pull call light response time reports. The facility's policy, revised in September 2022, emphasized the importance of timely responses to call lights, yet the observed and reported delays suggest a failure to adhere to this policy consistently.
Failure to Complete Physician's Orders for Two Residents
Penalty
Summary
The facility failed to complete physician's orders for two residents, leading to deficiencies in care. Resident #3, who had no cognitive impairment, was ordered tests for strep, flu, and COVID-19 by the ARNP due to a sore throat. However, the strep test was not completed on the same day as ordered, and there was confusion regarding the test panel used, which did not include the strep test. Despite multiple follow-ups by the ARNP, the test was delayed, although the resident's symptoms resolved without treatment. Resident #4, who had severe cognitive impairment, had a left heel wound that required a wound culture, wound care consult, and duoderm dressing as ordered by the ARNP. The wound culture was delayed, and the duoderm dressing was not initiated as ordered. The wound care consult was not set up, and the resident's condition worsened, leading to hospitalization and subsequent hospice care. The DON acknowledged the oversight and attempted to address the issue, but the consult was not completed before the resident's hospitalization. The facility's process for handling physician orders was inadequate, leading to missed and delayed orders. The DON was on vacation during the time of the deficiencies, and there was a lack of follow-up by the ADON. The facility's policy on medication and treatment orders was not followed, resulting in the deficiencies noted in the report.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance to three residents who were dependent on staff for Activities of Daily Living (ADLs) care, specifically when they were incontinent of urine and/or bowel. Resident #5, who had no cognitive impairment and was frequently incontinent of bowel, reported that she was left in soiled clothing overnight despite requesting assistance. Her care plan indicated she required substantial assistance for bed mobility and was dependent on staff for toilet hygiene, yet she was not adequately attended to. Resident #7, with mild cognitive impairment and a history of stroke, was always incontinent of urine and frequently incontinent of bowel. He required assistance from staff for bed mobility and toileting. Despite this, he indicated that there were times when his bedding needed changing due to incontinence, suggesting inconsistent care. His care plan directed staff to ensure he was clean and dry with each check and change, which was not consistently followed. Resident #8, who had no cognitive impairment and was always incontinent of bowel and bladder, reported having to wait approximately 30 minutes to be cleaned up after becoming incontinent at night. Staff interviews revealed that residents were often found soaked in urine or feces after the overnight shift, indicating a pattern of neglect in providing timely incontinence care. The Director of Nursing acknowledged the issue and mentioned efforts to address it, but the deficiency persisted, affecting the residents' dignity and comfort.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement timely and appropriate interventions to prevent the worsening of pressure sores for two residents. Resident #16 developed a pressure sore on her heel, which was not promptly treated according to physician orders. The staff delayed the application of prescribed treatments and failed to use the recommended Prevalon boots consistently, which are essential for off-loading pressure from the heel. The wound care nurse practitioner noted that the resident's wound deteriorated rapidly, with increased pain, odor, and slough, indicating infection. Despite the worsening condition, the staff did not report these changes promptly, and the resident was eventually hospitalized for further treatment. Resident #17, who was dependent on staff for dressing and toileting, had a chronic pressure area on his buttocks. The staff failed to apply the recommended barrier creams after each incontinence episode, as outlined in the care plan. During an observation, CNAs did not apply barrier cream to the resident's reddened spots and open area on the thigh, despite the resident's complaint of pain. The facility's policy on pressure injury prevention, which includes the use of barrier products to protect the skin from moisture, was not followed. The facility's failure to adhere to care plans and physician orders, along with inadequate communication among staff, contributed to the deterioration of the residents' conditions. The lack of timely intervention and proper use of pressure-relieving devices and barrier creams resulted in the worsening of pressure sores, leading to increased pain and infection for the residents involved.
Failure to Follow Physician Orders and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide a professional standard of quality care by not following physician orders and failing to maintain continence for two residents. Resident #61, who had a BIMS score indicating no cognitive deficit, was diagnosed with a urinary tract infection (UTI) and septicemia. Despite having an indwelling catheter, the facility did not rate urinary continence. The resident's care plan included monitoring for signs of UTI and incontinence, but the facility did not act promptly when the resident's daughter reported symptoms of a UTI. The nurse faxed a request for a urinary analysis (UA) instead of calling the on-call provider, leading to delays in diagnosis and treatment. The resident was eventually hospitalized for acute kidney injury, pneumonia, and UTI. Resident #17, with a BIMS score indicating intact cognitive ability, was totally dependent on staff for dressing and toileting hygiene. The resident was frequently incontinent of urine and always incontinent of bowel due to a neurogenic bladder and spinal cord injury. Despite the care plan directing staff to apply barrier cream and monitor for incontinence, the resident was found with soaked protective pads and soiled shorts, indicating a lack of timely incontinence care. Staff reported that the resident had stopped asking for help with the urinal, leading to increased incontinence. The facility's failure to follow physician orders and provide timely incontinence care resulted in significant health issues for both residents. The Director of Nursing acknowledged a breakdown in communication and order completion, which contributed to the deficiencies. The facility's policy required staff to offer toileting assistance every two hours, but this was not consistently followed, leading to the residents' deteriorating conditions.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to four residents, as observed through resident interviews, staff interviews, and resident council notes. Resident #52, with no cognitive impairment, reported that the food was often cold when it should be warm. Resident #59, also with no cognitive impairment, stated that corn dogs were served cold and that the kitchen manager did not listen to complaints about the food. Resident #59 further mentioned that food was frequently cold and that many residents complained about the food during monthly meetings. A temperature check of a meal intended for Resident #59 revealed that the beef stroganoff was at 132 degrees and the brussels sprouts at 111 degrees, which was below the expected temperature. Resident #25, who required setup for meals and had no cognitive deficit, reported that the food was often cold and the pasta was mushy. Resident #61, also with no cognitive deficit, stated that meals were not always hot and left most of her food uneaten because it was not hot enough. Staff interviews revealed that the dietary cart had been out of the kitchen for about 20 minutes before a temperature check was conducted. The facility's policy on food preparation and service indicated that proper hot and cold temperatures should be maintained during food service, but this was not adhered to, leading to the deficiency.
Failure to Follow Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation, food safety, and food handling practices as observed during a survey. Staff members, including cooks and dietary aides, were noted to have facial hair without appropriate coverings, contrary to the facility's policy requiring hair and beard restraints. Observations revealed that food items were served without proper coverings, and staff members did not consistently perform hand hygiene before and after glove use or when entering the kitchen. Specifically, a cook and dietary aides were seen handling food and trays without following hand hygiene protocols, and one dietary aide used individual glasses instead of a scoop to add ice to beverages. The facility's policies on food preparation and hand hygiene, revised in 2019, were not followed by the staff. These policies require hand hygiene before serving food, after handling soiled items, and before and after glove changes. Additionally, food and drink items for delivery should be covered, and staff must use scoops for ice. The dietary manager confirmed these requirements and acknowledged the lapses in adherence to the policies. The facility reported a census of 65 residents at the time of the survey.
Failure to Update PASRR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a Pre-Admission Screening and Resident Review (PASRR) for a resident who was diagnosed with new mental disorder diagnoses since admission. The resident, identified as Resident #25, had a Minimum Data Set (MDS) assessment indicating no cognitive deficit and was diagnosed with anxiety disorder, depression, and post-traumatic stress disorder (PTSD). Despite these diagnoses, the facility's PASRR Notice of Nursing Facility Approval did not reflect the need for PASRR intervention, and the screen was considered valid for the resident's stay. However, the resident's electronic health record revealed additional diagnoses of generalized anxiety disorder, PTSD, insomnia, and major depressive disorder, with corresponding physician orders for medications. During interviews, facility staff acknowledged the oversight in updating the PASRR for Resident #25. The Social Service Designee admitted that the new diagnoses had been missed, and a new PASRR had not been completed. The facility administrator further explained that an audit conducted 6-9 months prior had identified a need for multiple PASRR updates due to unnotified additions of diagnoses by a provider. The facility lacked a policy for updating PASRRs when residents received new mental health diagnoses, leading to the deficiency in Resident #25's case.
Incomplete Documentation of Enteral Feeding Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident requiring enteral feeding, as evidenced by unsigned medication administration records (MAR) and treatment administration records (TAR) over several months. The resident, who had no cognitive impairment, reported that the evening nurse sometimes forgot to turn on the feeding pump, which was then discovered by the morning nurse. Despite these lapses, the resident stated she did not miss any feedings. Staff interviews revealed inconsistencies in the documentation process, with some nurses admitting to not signing the MAR when feedings were administered outside the scheduled times. The Director of Nursing (DON) confirmed that the facility's policy required nurses to document in the MAR and enter a progress note if feedings were not started or delayed. However, the policy was not consistently followed, leading to gaps in the records. The facility's policy on administering medications required the individual administering the medication to sign the MAR with their signature and title, which was not adhered to in this case. This deficiency was identified through resident and staff interviews, as well as a review of the electronic health records and facility policies.
Inadequate Infection Control and EBP in LTC Facility
Penalty
Summary
The facility failed to provide adequate hand hygiene and Enhanced Barrier Precautions (EBP) for three residents. For Resident #17, who had a BIMS score of 15 and was dependent on staff for dressing and toileting hygiene, staff did not change gloves during incontinence care. Staff A and Staff B, both CNAs, were observed transferring the resident and providing care without changing gloves after wiping feces, which is against the expected protocol as stated by the Director of Nursing (DON). Resident #25, with a BIMS score of 15 and diagnosed with renal insufficiency and a multidrug-resistant organism (MDRO), required EBP due to a permacath. During a post-dialysis assessment, Staff J, an LPN, did not utilize any PPE, including gown, gloves, or mask, despite the resident's increased risk for infection. The facility's policy and the DON's statement indicated that EBP should have been followed, especially given the resident's indwelling medical device. For Resident #21, who had a BIMS score of 10 and an indwelling catheter, Staff B, a CNA, did not apply a gown during catheter care, although gloves were used. The facility's policy and the DON's statement confirmed that gowns and gloves should have been worn during such procedures. The Centers for Disease Control and Prevention guidelines also support the use of EBP for residents with indwelling medical devices, regardless of MDRO colonization status.
Failure to Address Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly address a grievance reported by a resident, who had no cognitive impairment as indicated by a BIMS score of 15. The resident reported missing money and tickets to two staff members, the Social Service Designee and the Business Office Manager. Despite the resident's report, no grievance was filed, and the issue was not resolved. The Social Service Designee was unaware of the missing money, and the Business Office Manager acknowledged the resident's report but did not follow through with the grievance process, assuming someone else would handle it. This lack of action led to the resident's grievance being unaddressed for several months. The facility's grievance policy requires staff to complete a Grievance Report Form when a grievance is not immediately resolved, but this procedure was not followed. The Administrator was unaware of the incident until much later and stated that the facility would replace the missing money. The policy review indicated that the grievance should have been documented and investigated, but this did not occur, resulting in a failure to uphold the resident's right to voice grievances without reprisal or discrimination.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Missouri Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Shepherd Lutheran Home | 13.6 mi | ★★★★★ | 11 | 0 |
| Crowell Memorial Home | 13.6 mi | ★★★★★ | 3 | 0 |
| Azria Health Rose Vista | 15.2 mi | ★★★★★ | 12 | 0 |
| Florence Home | 16.7 mi | ★★★★★ | 10 | 0 |
| Emerald Nursing & Rehab Legacy Pointe Llc | 17.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.