Azria Health Prairie Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Mediapolis, Iowa.
- Location
- 608 Prairie Street, Mediapolis, Iowa 52637
- CMS Provider Number
- 165220
- Inspections on file
- 26
- Latest survey
- January 30, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Azria Health Prairie Ridge during CMS and state inspections, most recent first.
A resident with multiple medical conditions and moderate cognitive impairment, seated near the nurses’ station while on the phone, swung his arm back and struck another resident with severe dementia twice in the upper back as she self-propelled her wheelchair past him, following her usual routine. Staff reported that this resident could become irritable when redirected, and he then stood up and hit and pinched a CNA who intervened. The aggressor’s care plan identified mood and behavior issues and directed staff to anticipate needs, provide positive interaction, and intervene to protect others’ safety, while the other resident’s care plan addressed impaired cognition and the need for supervision and consistent routine. The facility’s abuse policy states residents must be protected from abuse by anyone, including other residents.
A resident with multiple chronic conditions, moderate cognitive impairment, and dependence on staff for mobility allowed a CNA to use her EBT food stamp card to buy snacks for her and also to purchase items for the CNA, without specifying a spending limit. The CNA used the card at a grocery store to buy a large volume of items, and later could not clearly recall what she had purchased for herself. When the receipt was reviewed, the resident identified numerous items she had not requested that were believed to be for the CNA, totaling a substantial amount. Other staff reported they understood from dependent adult abuse training that using a resident’s resources or accepting gifts was wrong, and facility policy explicitly prohibited exploitation and misappropriation of resident property, yet the resident’s EBT benefits were used inappropriately by staff.
Two residents were issued emergency discharges following repeated altercations, with the facility failing to adequately address their needs or properly notify and involve their guardians and families in the process. Both residents were transferred to hospitals for psychiatric evaluation, found not to require admission, and were subsequently refused readmission by the facility, resulting in one resident remaining hospitalized and the other returning to independent living with limited support.
Surveyors identified multiple instances where staff failed to store raw meat on the bottom shelf, handled food with gloved hands without changing gloves between tasks, and left an ice scoop handle in contact with ice. Staff interviews confirmed awareness of proper procedures, but these were not consistently followed, resulting in unsanitary food storage and handling.
The facility did not ensure that its services met professional standards of quality, as observed through practices that did not align with established care guidelines.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Three medication errors were observed among twenty-seven opportunities, resulting in a medication error rate of 11.11%. Errors included a resident receiving insulin after eating instead of before meals, another resident receiving the wrong dosage form of Ferrous Sulfate, and a third resident being given a different formulation of Polyethylene Glycol than prescribed. These incidents occurred despite facility policies requiring medications to be administered as ordered and within specified time frames.
Multiple residents experienced significant medication errors involving anticoagulants, insulin, and narcotic pain medications due to failures in documentation, communication, and order transcription. In several cases, residents received double doses of medications or had medications administered at incorrect times, and one resident received an incorrect anticoagulant regimen due to a transcription error that was not clarified with the discharging hospital. These errors were identified through observation, interviews, and record review, and were not consistent with the facility's medication administration policy.
Three residents experienced a lack of dignity and respect due to staff actions, including inappropriate verbal and physical cues during feeding, use of personal phones during care, and inadequate supply of properly sized incontinence briefs. These actions were confirmed by resident and staff interviews, observations, and review of facility policies, highlighting failures to follow care plans and maintain resident dignity.
A resident with multiple chronic conditions experienced significant weight loss over several months. Although dietary staff documented the weight loss and implemented interventions, the facility failed to provide evidence that the physician was notified of these changes, as required by policy.
Care plans were not updated for two residents who experienced significant weight loss and for another resident who was no longer receiving dialysis, despite clear evidence of these changes. Staff interviews revealed lapses in responsibility for updating care plans, and the facility's policy requiring timely revisions after significant changes was not followed.
A resident with lower extremity impairment and intact cognition did not consistently receive restorative nursing interventions as recommended by therapy, due to inconsistent staff assignment and lack of dedicated restorative personnel. The care plan outlined specific exercises and activities, but staff interviews revealed that restorative programming was often missed or inadequately implemented when the responsible staff member was reassigned to other duties.
The facility failed to complete quarterly MDS assessments on time for several residents, with delays noted in the completion of assessments beyond the required 14-day period from the ARD. Interviews with staff, including the MDS Coordinator and DON, confirmed these delays, and the facility's policy did not address quarterly MDS requirements.
A facility failed to update a PASRR for a resident with new mental health diagnoses and medications. The resident had a history of anxiety, depression, and psychotic disorder, and was taking antipsychotic and antidepressant medications. Despite significant changes in diagnoses and medication orders, the PASRR was not resubmitted. The MDS coordinator misunderstood the criteria for significant changes, which was later clarified by the administrator. The facility's policy required a PASRR Level II evaluation for new or changed behaviors indicating a serious mental disorder, but this was not followed.
A facility failed to administer a pneumococcal vaccine to a resident who was eligible for the PCV 20 vaccine. The resident had previously received the Prevnar 13 vaccination and consent for the PCV 20 was obtained. However, due to a lack of communication and clarity among staff regarding responsibility for vaccinations, the vaccine was not administered. The DON relied on the Infection Preventionist, who was unaware of the need to offer the vaccine, resulting in a disconnect in the process.
The facility did not complete annual MDS assessments on time for two residents. One resident's assessment was still in process beyond the required timeframe, while another's was completed late. Staff interviews confirmed the delay, which was against the facility's policy requiring completion within 14 days of the ARD.
The facility failed to maintain a clean and hazard-free environment, with observations of debris and trash under beds, cluttered hallways, and inconsistent cleaning practices. A resident reported that their room was not always cleaned thoroughly, contributing to the deficiency.
The facility failed to follow enhanced barrier precautions and hand hygiene practices. A resident on enhanced barrier precautions was assisted by CNAs without protective gowns. Another resident received care without staff sanitizing hands before providing a snack. Observations revealed empty sanitizer dispensers and staff not using them, violating the facility's hand hygiene policy.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse in the form of a resident-to-resident altercation. On the date of the incident, one resident was seated near the nurses’ station while using the phone, and another resident, who routinely self-propelled her wheelchair around the nurses’ station in the evenings, attempted to pass by. As the second resident tried to pass, the seated resident swung his arm back and struck her twice in the upper back. This event was witnessed by a restorative aide and a registered nurse, and was later documented in nursing progress notes and a facility-reported incident. The resident who initiated the altercation had multiple medical diagnoses, including cerebrovascular accident, hemiplegia, aphasia, adjustment disorder with depressed mood, a history of falls, and diabetes. His most recent MDS prior to the incident showed a BIMS score of 9/15, indicating moderate cognitive impairment, and documented that he was usually able to make himself understood and to understand others. His care plan identified mood and behavior issues, including verbal aggression and a tendency to not want to wear clothes, and directed staff to anticipate and meet his needs, assist with coping and interacting, provide positive interaction, discuss inappropriate behavior when reasonable, and intervene as necessary to protect the rights and safety of others by approaching calmly, redirecting, and removing him from situations as needed. The resident who was struck had diagnoses including non-Alzheimer’s dementia, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood, with a BIMS score of 6/15 indicating severe cognitive impairment. She was sometimes able to make herself understood and to understand others, and used a wheelchair as her primary mode of transport. Her care plan addressed impaired cognitive function and directed staff to ask yes/no questions, cue, reorient, supervise as needed, keep her routine consistent, and provide consistent caregivers. On the day of the incident, she was following her usual routine of self-propelling around the nurses’ station when she was hit. Staff interviews described that the striking resident could become irritable when redirected and that he hit the other resident before staff could intervene, then stood up and subsequently hit and pinched the CNA who attempted to stop him. The facility’s abuse prevention policy states that residents have the right to be free from abuse by anyone, including other residents, and that the facility will protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone.
Failure to Protect Resident From Financial Exploitation of EBT Food Benefits
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from financial exploitation by a staff member. The resident had multiple diagnoses including adult failure to thrive, type 2 diabetes with complications, alcoholic cirrhosis of the liver, anxiety, and depression, and had a BIMS score indicating moderate cognitive impairment, though she was always able to make herself understood and to understand others. She was totally dependent on staff for substantial assistance with repositioning, transfers, and was unable to stand or ambulate. Her care plan identified that she had difficulty coping with lifestyle changes, limitations in functional abilities, and the loss of her husband as caregiver, and that she needed assistance with problem solving and psychosocial support. The events leading to the deficiency began when the resident, who received monthly EBT food stamp benefits, asked a CNA to use her EBT card to purchase snacks for her and told the CNA she could also buy items for herself with the card. The resident did not specify an amount the CNA could spend, did not know exactly what the CNA purchased for herself, and recalled the total purchase being a little over $100. Some purchased items required refrigeration and were placed in a refrigerator outside the resident’s direct control, and the resident later reported she had lost track of those items. The resident stated she did not think she had done anything wrong and was unaware at the time that designated facility staff were available to shop for residents. Interviews and document review showed that the CNA acknowledged using the resident’s EBT card at a grocery store, spending a little over $100, and purchasing food for both the resident and herself, but could not clearly recall all items she bought for herself. A grocery store receipt showed 68 items purchased for a total of $268.93 with the resident’s EBT card. When the receipt was later reviewed with the resident, she identified several items totaling $115.96 that she stated she had not requested and believed were purchased for the CNA. Other staff, including another CNA/Restorative Aide, stated they knew it was wrong to use a resident’s resources or accept gifts from a resident based on dependent adult abuse education. The facility’s abuse, neglect, exploitation, and misappropriation prevention policy required protection of residents from exploitation and misappropriation of property, development of protocols to prevent and identify such incidents, and investigation of possible misappropriation, underscoring that the resident’s funds were wrongfully used by staff despite these policies.
Failure to Meet Resident Needs Prior to Emergency Discharge
Penalty
Summary
The facility failed to make adequate attempts to meet the needs of two residents prior to issuing emergency discharges following a series of resident-to-resident altercations. Both residents had intact cognitive status, as indicated by their BIMS scores, and required varying levels of assistance with activities of daily living. The clinical records showed a pattern of verbal disputes and threats of violence between the residents and their peers, with interventions primarily consisting of moving residents to different rooms and de-escalating situations. On the date of the final altercation, the facility obtained orders for emergency psychiatric evaluations and arranged for both residents to be transferred to local hospitals. The process of discharge was initiated while the residents were at the hospitals, with the facility citing the safety of individuals in the facility as the reason for the emergency discharges. The discharge forms included information about placement and appeal rights, but there were lapses in communication with the residents' guardians and family members. One resident's guardian was not informed about the appeals process and did not receive any forms to sign, while the other resident's family could not be reached prior to the discharge. Both residents were ultimately not admitted to the hospitals for psychiatric reasons, and the facility refused to readmit them upon the hospitals' requests. Interviews with facility staff revealed that the decision to discharge was made due to a perceived lack of available rooms to accommodate residents with behavioral issues. The staff also demonstrated a lack of awareness regarding the proper notification and involvement of guardians in the discharge process. As a result, one resident remained hospitalized while the other was taken to his apartment by family members, with concerns noted about his ability to manage medications and daily living needs.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and handling practices within the facility's kitchen. Raw hamburger was found thawing in a metal basin on an upper shelf above meal trays, and frozen chicken breasts were placed on a refrigerator shelf above containers of fruit, contrary to facility policy requiring raw meat to be stored on the bottom shelf to prevent cross-contamination. Staff interviews confirmed that staff were aware of the correct procedures but did not consistently follow them, with several staff acknowledging the improper placement of raw meat and the risk of contamination. During meal service, staff were seen using tongs to remove buns from packaging and then using their gloved hands to handle the buns and other items without changing gloves between tasks. Additionally, an ice scoop was repeatedly left in the ice container with the handle in contact with the ice, and staff continued to use the scoop without changing gloves after touching other surfaces. Staff interviews revealed knowledge of proper glove use and ice scoop handling, but these practices were not consistently implemented. The facility's policy requires measures to prevent cross-contamination, including proper storage of raw meat, adherence to hygiene and sanitary practices, and changing gloves between tasks, all of which were not followed during the observations.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines for care delivery. The report notes that the facility did not maintain the expected level of quality in the services rendered, as required by regulatory standards. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident’s medical history or condition at the time of the deficiency were not provided in the report.
Medication Error Rate Exceeds Regulatory Standard
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, resulting in an observed error rate of 11.11%. This was identified through observation, interview, and record review, where three medication errors were found among twenty-seven opportunities for three residents. One resident, with intact cognition and a history of insulin use, received insulin after already consuming food, contrary to the prescribed administration of insulin before meals. Another resident, also with intact cognition and a diagnosis of anemia, was administered a 324 mg enteric-coated tablet of Ferrous Sulfate instead of the prescribed 325 mg oral tablet. A third resident, with intact cognition and a prescription for Polyethylene Glycol 1450, was given Clearlax 3350 instead of the ordered medication. The facility's policies require medications to be administered as prescribed, within specified time frames, and in accordance with prescriber orders. However, staff failed to follow these protocols, as evidenced by the administration of medications at incorrect times, incorrect dosages, and substitution of medications. These actions directly contributed to the facility's elevated medication error rate, exceeding regulatory standards.
Significant Medication Errors Due to Documentation and Communication Failures
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by multiple incidents involving the administration of anticoagulants, insulin, and narcotic pain medications. In one case, a resident with intact cognition and a physician order for Warfarin received a double dose due to a lack of communication and documentation between nursing staff and a medication aide during a shift change. The nurse administered the medication but did not document it, leading the medication aide to administer a second dose. This resulted in the resident receiving 8 mg instead of the prescribed 4 mg of Warfarin. Another incident involved a resident with diabetes who was prescribed sliding scale insulin. The LPN checked the resident's blood sugar and administered insulin after the resident had already eaten, contrary to the physician's order to administer insulin before meals. The blood sugar was recorded at 200 mg/dL, and 2 units of insulin were given, but the timing did not align with the prescribed protocol. A third resident, also with intact cognition, was prescribed oxycodone for chronic pain. Due to a similar breakdown in communication and documentation, both an LPN and a medication aide administered a 5 mg dose of oxycodone, resulting in the resident receiving a double dose. Additionally, a resident with severe pulmonary hypertension was prescribed Apixaban following hospital discharge, but a transcription error led to the incorrect entry of the medication order. The facility failed to clarify the discharge instructions with the hospital, resulting in the resident receiving an incorrect dosing regimen. These incidents were confirmed through interviews, record reviews, and direct observation, and were not in accordance with the facility's medication administration policy.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
Staff failed to treat three residents with dignity, as evidenced by multiple interviews, observations, and record reviews. One resident with severe cognitive impairment and a history of stroke and aphasia was repeatedly told by staff to chew and swallow his food, despite care plan instructions to avoid such directives. Staff were observed and reported to have taken away the resident's plate, rubbed his cheek in an aggressive manner, and used a mean tone when instructing him to eat. The speech therapist and physical therapist both confirmed witnessing inappropriate staff interactions, including frustration and aggressive verbal and physical cues, which made the resident feel 'disgusting.' The Director of Nursing acknowledged that telling the resident to swallow was a trigger and that staff should not touch the resident's cheek or plate. Another resident with intact cognition reported that staff on the third shift used their personal phones during work hours, making the resident feel undervalued and uncomfortable asking for help. Multiple staff interviews confirmed that personal phone use occurred during shifts, including during resident care and in hallways. The facility's cell phone policy prohibits personal phone use during working hours and in patient care areas, except for authorized business purposes, but staff and social services confirmed that the policy was not consistently followed, leading to resident dissatisfaction and irritation. A third resident, also with intact cognition and total incontinence, reported that the facility frequently ran out of appropriately sized incontinence briefs, resulting in the resident having to wear briefs that were too large or of a different type. Staff confirmed that supply shortages led to residents wearing incorrect sizes, which caused discomfort and skin issues. The staffing coordinator and Director of Nursing acknowledged the supply issues, with staff sometimes borrowing briefs from other rooms and residents being left without the correct size until new supplies arrived. The facility's policy requires staff to be trained on resident dignity and respect, but these incidents demonstrate a failure to uphold those standards.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for a resident on two separate occasions, as required by facility policy. The resident, who had intact cognition and multiple comorbidities including CHF, diabetes, COPD, morbid obesity, gout, hypothyroidism, and hyperlipidemia, experienced a weight loss of over 10% in six months and over 5% in one month. Documentation showed that the dietitian identified and documented the significant weight loss and made recommendations, including meal enrichment and weekly weights, and noted that faxes were sent to the clinician. However, the facility was unable to provide documentation that the physician was actually notified or made aware of the weight losses, despite multiple staff interviews and record reviews. The resident's care plan and dietary notes reflected ongoing monitoring and interventions for nutritional risk, including the use of supplements and meal enrichment strategies. The resident herself was aware of her weight loss and attributed it to poor appetite following her husband's death and a recent illness. Despite these interventions and awareness by dietary staff, there was no evidence in the medical record or from staff that the physician was notified of the significant changes in the resident's condition, as required by the facility's policy on change in condition.
Failure to Update Care Plans After Significant Changes in Resident Condition
Penalty
Summary
The facility failed to update care plans in a timely manner for three residents following significant changes in their conditions. One resident experienced a significant weight loss of over 10% in six months, as documented in the weight summary, but the care plan was not updated to reflect this change. Another resident, who was at nutritional risk due to multiple medical conditions and had severely impaired cognition, also experienced a weight loss of nearly 15% over five months, yet the care plan did not reflect this significant change. Staff interviews confirmed that the care plans for both residents should have been updated to address the significant weight loss, but this was not done, partly due to a recent change in dietician staffing and unclear responsibilities for updating care plans. Additionally, a third resident's care plan continued to indicate the need for dialysis, despite the resident no longer receiving dialysis services. The resident and staff interviews confirmed that the resident had not been on dialysis for some time, and the care plan had not been revised to reflect this change. The facility's policy requires care plans to be revised when there is a significant change in a resident's condition, but this was not followed in these cases.
Failure to Implement Restorative Nursing Program for Resident with Mobility Impairment
Penalty
Summary
A deficiency occurred when the facility failed to implement a restorative nursing program as recommended by therapy for a resident with impaired lower extremity mobility. The resident, who was cognitively intact and had no upper extremity impairment but did have lower extremity impairment, reported only participating in restorative exercises once. The care plan indicated a need for restorative programming to maintain functional mobility and prevent decline, with specific interventions outlined, including the use of a seated bike, sit-to-stand activities, and lower extremity strengthening and stretching exercises. Despite these documented interventions, staff interviews revealed inconsistent implementation of the restorative program. The staff member primarily responsible for restorative care was frequently reassigned to other duties, such as providing showers, and could not explain how restorative programming was completed when working on the floor. No other staff were officially assigned to restorative programming, and coverage was sporadic. The Restorative Nurse's involvement was limited to documentation assistance, and the Director of Nursing stated that nurses were expected to fill in if the primary staff was unavailable. The facility's policy allowed for restorative nursing care upon discharge from therapy, but the recommended program was not consistently followed.
Failure to Complete Quarterly MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed in a timely manner for five residents out of nineteen reviewed. Specifically, the assessments for Residents #9, #18, #26, #29, and #34 were not completed within the required timeframe. For instance, Resident #18's assessment had an Assessment Reference Date (ARD) of 4/25/24, but the completion date was 5/20/24. Similarly, Resident #26's assessment with an ARD of 8/9/24 was still in process at the time of the review. Other residents also experienced delays in the completion of their assessments, with completion dates extending beyond the 14-day requirement from the ARD. Interviews with facility staff, including the MDS Coordinator, Director of Nursing (DON), and the Administrator, confirmed the delays in completing the MDS assessments. The MDS Coordinator acknowledged the lateness of the assessments for Residents #18 and #26. Both the DON and the Administrator expressed their expectations for timely completion of the MDS assessments. Additionally, the facility's Comprehensive Assessment Policy, dated December 2023, did not address the requirements for quarterly MDS assessments.
Failure to Update PASRR for Resident with New Diagnoses and Medications
Penalty
Summary
The facility failed to resubmit a PASRR (Preadmission Screening and Resident Review) for a resident with new mental health diagnoses and psychotropic medications added to their plan of care. The resident, who was reviewed for PASRR, had a history of anxiety disorder, depression, and psychotic disorder, and was taking antipsychotic and antidepressant medications. Despite these changes, the PASRR Level 1 Screen Outcome indicated no Level II was required unless a significant change occurred. However, the resident's care plan and medical records showed significant changes, including new diagnoses of major depressive disorder with psychotic symptoms and delusional disorders, as well as new medication orders for Depakote, Duloxetine, and Seroquel. The MDS coordinator, during an interview, acknowledged a misunderstanding regarding what constituted a significant change, believing it only applied to hospital admissions for mental issues. The administrator later clarified that changes in medications and medical diagnoses also required a new PASRR. The facility's policy stated that new onset or changes in behavior indicating a serious mental disorder should be referred for a PASRR Level II evaluation. Despite this policy, the necessary PASRR update for the resident was not completed, leading to the deficiency.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer a pneumococcal vaccine to Resident #8, who was eligible for the PCV 20 vaccine. The resident had previously received the Prevnar 13 vaccination in 2019 and was noted to be eligible for the PCV 20 as of February 13, 2024. The resident's immunization record was reviewed by the ARNP, and verbal consent for the vaccine was obtained from the resident's daughter, with education provided on the risks and benefits. However, the vaccine was not administered. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for administering the vaccine. The DON stated that he relied on the Infection Preventionist to manage vaccinations, but the ADON/IP was unaware of the need to offer the vaccine to Resident #8. The DON acknowledged the oversight and expressed an expectation for follow-through, but there was a disconnect in the process, resulting in the resident not receiving the vaccine. The facility's policy indicated that pneumococcal vaccines should be administered per CDC recommendations, but this was not followed in this instance.
Delayed MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure timely completion of annual Minimum Data Set (MDS) assessments for two residents, as required by their policy. Resident #18's MDS assessment, with an assessment reference date (ARD) of July 25, 2024, was still in process at the time of the survey. Resident #26's MDS assessment, with an ARD of May 9, 2024, was completed on June 3, 2024, indicating a delay. Interviews with the MDS Coordinator, Director of Nursing (DON), and the Administrator confirmed the assessments were late and should have been completed within 14 days of the ARD. The facility's Comprehensive Assessments Policy mandates that annual assessments be completed at least every 366 days unless a significant change or correction assessment has been conducted since the last comprehensive assessment.
Failure to Maintain Clean and Hazard-Free Environment
Penalty
Summary
The facility failed to maintain a clean and hazard-free environment for its residents, as evidenced by multiple observations of unclean conditions in resident rooms and cluttered hallways. On several occasions, debris such as rubber gloves and trash were found under the bed in a resident's room and remained there for multiple days despite housekeeping services being performed. Additionally, a gown and deodorant container were observed on the floor in another room, with the deodorant container remaining even after partial cleaning. Hallways were also noted to be cluttered with mechanical lifts, standing devices, and wheelchairs, posing potential hazards. Interviews with staff and residents further highlighted the deficiency in maintaining cleanliness. The Housekeeping and Laundry Supervisor stated that resident rooms are supposed to be cleaned daily, including sweeping, mopping, and sanitizing, with deep cleaning scheduled for one room per hall each day. However, a resident reported that their room was not consistently cleaned, with housekeeping often neglecting areas under or behind furniture. This inconsistency in cleaning practices contributed to the observed deficiencies in maintaining a safe and clean environment.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to adhere to enhanced barrier precautions and consistent hand hygiene practices, as observed during a survey. Resident #6, who has intact cognition and requires moderate assistance with daily activities, was on enhanced barrier precautions due to a catheter. However, during personal care, two CNAs, Staff E and Staff F, did not wear protective gowns as required. Both staff members acknowledged the oversight during interviews, with one stating she forgot to wear a gown. Additionally, Resident #5, who is severely cognitively impaired and dependent on staff for assistance, was observed receiving care without proper hand hygiene practices being followed. Staff G and Staff H assisted with transfers and incontinence care but did not sanitize hands before providing a snack to the resident. Furthermore, sanitizer dispensers were found empty, and staff were not observed using them. Other staff members, including a registered nurse and a CNA, were also seen assisting multiple residents without sanitizing their hands between contacts, contrary to the facility's hand hygiene policy.
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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 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.
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.
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.
Two residents who were cognitively impaired and dependent on staff for personal care did not receive bathing assistance at least twice weekly as required by facility policy. Facility records showed multiple instances where bathing was documented as refused or not applicable, resulting in gaps of 6, 7, and 11 days between baths. The care plan for one resident specified total dependence on staff for bathing, and the facility’s policy required showers to be offered at least twice weekly and on the next available day if missed. The DON reported that staff are expected to continue offering showers and try different approaches after refusals, but the documented bathing intervals did not reflect this practice.
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.
A resident with COPD, pneumonia, and respiratory failure was transferred to the hospital for acute respiratory distress and later deemed medically ready for discharge, but the facility delayed readmission by three days due to staffing and admission timing practices. Facility staff, including an RN, MDS coordinator, ADON, DON, and Administrator, reported that they avoided weekend and evening admissions, required two nurses for admissions, and were concerned about entering medication orders into the EMR in time for pharmacy delivery when only one nurse was on duty. They did not notify the provider about the planned discharge back, did not arrange alternative pharmacy or transport options, and cited shared transport and lack of additional nurses as reasons the readmission was not feasible, despite the facility’s stated commitment to 24-hour nursing care and medication management.
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.
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.
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 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.
Failure to Provide Twice-Weekly Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance at least twice weekly, as required by its own policy, for two residents who were dependent on staff for bathing. For one resident with anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive impairment, the MDS documented total dependence on staff for bathing. Facility documentation showed that bathing was recorded as refused on one date, with actual baths provided on dates that resulted in a 6‑day interval without a bath on two separate occasions. The resident’s care plan indicated the resident was totally dependent on staff to provide a bath as necessary. For another resident with diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, facility records showed multiple dates where bathing was documented as refused or as not applicable. Review of the Follow Up Question Report demonstrated several extended gaps between baths: 6 days on two occasions, 7 days on one occasion, and 11 days on another, despite the facility policy requiring showers to be offered at least twice weekly and, if missed, to be offered on the next available day. In an interview, the DON stated that when a resident refuses a shower, staff are expected to continue to offer, try multiple times, try a different person, and continue to try the next day until the resident bathes, which was not reflected in the documented bathing intervals for these two residents.
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.
Delayed Hospital Readmission Due to Insufficient Nursing Staff and Admission Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and related processes to support the timely readmission of a hospitalized resident, resulting in a three-day delay in the resident’s return. The resident had moderately impaired cognition, with a BIMS score of 12/15, and medical diagnoses including COPD with acute exacerbation, pneumonia, and respiratory failure. The resident was transferred to the hospital after staff observed labored respirations, use of accessory muscles, diaphoresis, an oxygen saturation of 85% on room air, and wheezing, with improvement after oxygen was applied but continued labored breathing. Hospital records show the resident was admitted and later determined medically stable and ready for discharge, with documentation that the patient was planned for discharge but was not accepted back to the facility due to timing issues and would remain in the hospital over the weekend. Hospital progress notes documented that the resident was medically ready for discharge and that discharge was planned but not completed because the facility would not accept the resident later in the day. A hospital case management/social work note indicated confirmation that the facility could take the patient on the day the resident ultimately returned. The facility’s EHR showed the resident’s billing status changed to STOP BILLING on the date of hospital transfer and back to active several days later, corresponding to the delayed readmission. The resident reported spending three days in the hospital before being able to return to the facility. Multiple staff interviews described facility practices that contributed to the delay in readmission. An RN stated the facility tried not to do admissions on weekends and did not want admissions after 2 p.m. so nurses could complete admission tasks and enter medications into the computer in time for pharmacy delivery. The MDS Coordinator stated the facility liked residents readmitted before 2 p.m. to obtain medications, that the hospital had informed them the resident would not return until early evening, and that the facility needed two nurses in the building for an admission; the coordinator also stated the facility did not do admissions on weekends and was unsure about using another pharmacy or family to obtain medications. The ADON and DON both stated that with only one nurse on duty, a readmission later in the day was not feasible due to the time needed for admission assessments and medication entry, and they cited concerns about not having medications on time and the workload of one nurse caring for existing residents and completing a readmission. The DON further stated the facility did not accept evening or Saturday admissions for safety reasons, did not notify the provider about the planned discharge back to the facility, and did not explore hospital-supplied medications or alternative transport options, while acknowledging the presence of on-call nurses. The Administrator confirmed that with only one nurse, a readmission was considered not doable. The facility lacked written transportation or readmission policies and relied on general CMS and Resident Rights guidance, while its Resident Handbook stated residents receive individualized 24-hour nursing care and medication management.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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