Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Bethany Life during CMS and state inspections, most recent first.
A resident with intact cognition and transfer dependence suffered a 2nd degree abdominal burn after use of a microwavable heat pack, then later had an intercepted fall with a left foot injury and incomplete documentation/follow-up of the event. Another cognitively intact resident who required 1-person assist with a gait belt fell when a CNA briefly let go of the gait belt while moving a wheelchair during a toilet transfer.
The facility failed to notify the LTC Ombudsman of the discharge and/or transfer of 3 residents. Records showed one resident discharged without an anticipated return, another discharged with an anticipated return and later listed on unpaid hospital leave, and a third resident discharged with an anticipated return and later on hospital paid leave before discharge. Staff acknowledged the monthly Ombudsman notification lists did not include these residents, and the Administrator stated the facility did not have a policy on Ombudsman notification.
A medication pass error occurred when an RN prepared meds for two residents at the same time and placed one resident’s med cup behind another resident’s TV. A resident with moderately impaired cognition grabbed the other resident’s meds and swallowed two pills before staff could remove them. The meds were carbidopa/levodopa ER and melatonin. Staff later stated she was running behind, and the MDS Coordinator said meds were expected to be prepared and passed to one person at a time with eyesight on the medications.
Nebulizer tubing and mask were not changed for a resident with asthma and COPD who received scheduled and PRN nebulizer treatments. Staff observed tubing still dated from weeks earlier, and the ADON acknowledged it had not been changed since that date. The care plan addressed nightly cleaning, but the orders and TAR did not specify tubing or mask change frequency.
A resident with intact cognition and significant transfer assistance needs had a witnessed fall that was not reported to the PCP until several days later. The facility also failed to follow up on MRI results for the resident’s left foot injury or communicate the findings to the ordering physician; staff said the resident handled her own appointments and results, and the DON reported there was no policy for physician notification/communication.
A medication error deficiency was cited again at the current survey after the same concern had already been identified in prior complaint surveys. The facility’s QAPI policy described a process for tracking performance, identifying quality deficiencies, and analyzing causes, and the DON stated medication errors had been discussed in QAPI meetings, but also acknowledged repeat concerns with medication errors remained.
A cognitively intact resident who required total assistance with toileting and was frequently incontinent told a CNA during a nighttime incontinence round that she was dry and did not want to be bothered. Despite this refusal, the CNA proceeded to check her by placing a hand between her thighs to feel the outside of her brief, then left without changing her. On a subsequent round, the resident again refused to be checked, and the CNA then obtained the nurse. The resident later reported feeling uncomfortable, fearful that her wishes would not be respected, and having trouble sleeping after the incident. Staff interviews and documentation confirmed the resident’s account and that the action conflicted with the resident’s care plan and stated rights to dignity and self-determination.
A resident with moderately impaired cognition, dementia diagnoses, significant visual impairments, and identified on the care plan as an elopement risk who wore a wander alert pendant left the facility through a north door and later returned with staff, but this incident was not documented in the clinical record. Facility records showed conflicting information about the resident’s assigned household, and despite established expectations in the nurse competency checklist that unusual events and incidents be documented, the DON decided not to document the occurrence because it was not considered an actual elopement.
A resident with a history of CHF, hypertension, and renal failure did not receive prescribed PRN Lasix when their weight increased by 3 pounds from baseline, as directed by the physician. Despite clear orders and documentation of weight increases, staff did not administer the diuretic on several occasions, and this was confirmed through record review and staff interview.
Failure to Provide Dignified and Respectful Peri-Care: A resident with severe cognitive impairment, bowel incontinence, and multiple medical conditions was reportedly handled too quickly during peri-care by a CNA. Another CNA reported the resident was rolled rapidly and said "ow" during care, while the resident later stated he did not feel safe during the activity. The clinical record lacked documentation of the incident, and the Administrator confirmed staff are expected to treat residents with dignity and respect at all times.
Failure to timely report alleged mistreatment incident. A resident with severe cognitive impairment, bowel incontinence, and dependence for toileting hygiene experienced a peri-care incident in which staff described moving him quickly while cleaning stool from his buttocks, and the resident said “ow” and later stated he did not feel safe during the care. The facility’s record lacked documentation of the incident, and the Administrator confirmed the allegation was not reported to DIAL within the required 2-hour timeframe.
Failure to protect a resident during peri-care after an abuse allegation. A CNA was accused of being rough and slamming a resident while providing peri-care to a resident with severe cognitive impairment, bowel incontinence, and a hemorrhoid. Staff reported the resident said “ow” during care and later said he did not feel safe, but the RN did not treat the concern as abuse and allowed the CNA to keep working with other residents while the issue was being reviewed.
A resident with multiple diagnoses, including anxiety and insomnia, did not receive medications as ordered when staff administered lorazepam at night instead of the prescribed clonazepam, and missed several doses of clonazepam. This led to increased anxiety, insomnia, and a hospital evaluation. Staff interviews confirmed confusion between the two medications, and facility policy requiring correct medication administration was not followed.
Two residents with documented histories of sexually inappropriate behaviors and cognitive impairment were left unsupervised together, resulting in an incident of sexual abuse. Despite care plans indicating the need for constant supervision and staff awareness of the risks, only general directives to keep the residents apart were given, and no additional interventions were implemented. Staff reported challenges in supervision due to staffing levels and the residents' mobility, and facility leadership acknowledged the lack of adequate supervision and specific instructions.
A resident with moderately impaired cognition and requiring assistance with mobility experienced a delay in call light response, taking over 19 minutes for staff to respond. Interviews with CNAs confirmed that call light responses often exceeded the expected 15-minute timeframe, contrary to state and federal regulations.
A resident who required substantial assistance for transfers fell and sustained fractures after a CNA failed to use a gait belt, despite the resident's request and facility policy. The CNA was terminated for this violation.
A resident with dysphagia, dementia, and a history of stroke was not adequately supervised during meal times, leading to a choking incident. Despite documented needs for eating cues and specific Care Plan instructions, staff failed to provide necessary supervision. The CNA responsible was preoccupied with other tasks and did not notice the resident choking until alerted by another staff member. This incident underscores the importance of adhering to individualized care requirements, particularly for residents with swallowing difficulties.
The facility failed to respond to call lights in a timely manner for four residents, leading to significant delays in care. One resident had to take herself to the bathroom, another remained in bed due to lack of staff, and a third resident's wife had to leave the unit to find help after a fall. The facility's policy requires call lights to be answered within 15 minutes, but this was not adhered to.
The facility failed to document a critical incident in a resident's medical record following their death. The resident, who had dysphagia, dementia, and a history of stroke, experienced a hypoxic episode after consuming a brownie. Despite attempts to perform the Heimlich maneuver, the resident did not recover, and the incident was not documented until two weeks later, after the survey began.
The facility failed to ensure liquid Lorazepam was stored in locked compartments in two medication rooms and did not maintain medication refrigerators properly, leading to ice build-up and unclear responsibilities for cleaning and defrosting. Staff interviews and observations revealed issues with lock management and a lack of clear policies.
The facility failed to serve food at safe and palatable temperatures in the Sansgaard Household. Observations revealed several food items below the required 140 degrees Fahrenheit, and residents reported receiving cold meals. Staff D, unfamiliar with the household's temperature chart, did not reheat the food as per facility policy.
A resident with severe cognitive impairment was subjected to loud and stern communication by a CMA, causing visible distress. Despite the facility's protocol for handling resistant residents, the staff member's actions did not align with expectations for treating residents with dignity and respect.
The facility failed to update the care plan for a resident with severe cognitive impairment and multiple diagnoses, who developed an unstageable pressure ulcer. Despite the facility's protocol requiring a care plan intervention within 72 hours, the care plan lacked a focus area related to the pressure ulcer, which had been assessed and measured weekly since its discovery.
The facility failed to complete weekly skin assessments for a resident with severe cognitive impairment and multiple diagnoses, as required by the Care Plan and physician's orders. Documentation was missing for several weeks in 2023 and 2024, and staff interviews confirmed the assessments were not completed as mandated.
The facility's Dietary Staff failed to follow proper procedures for pureed food preparation for seven residents on a pureed diet. The cook did not measure the volume of pureed food and used water instead of nutritional fluids, contrary to the facility's policy. The Dietician confirmed that the observed process did not adhere to the guidelines.
The facility failed to provide appropriate catheter care for a resident with a suprapubic catheter. During an observation, a staff member was seen escorting the resident with catheter tubing dragging on the ground, which the resident stepped on multiple times. Interviews revealed that the resident often resists catheter care, and staff usually place excess tubing in a dignity bag, which was not done during the incident.
The facility failed to complete a discharge summary, including a recapitulation of stay, for a resident. The resident's electronic health record did not contain a discharge summary or a post-discharge plan of care. The Administrator confirmed that the recapitulation is done through the discharge progress note and that the facility had no interdisciplinary form or policy on recapitulation of stay.
Inadequate supervision during transfers and use of heating devices
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and injuries for two residents. Resident #12 had intact cognition, required substantial to maximal assistance with bed mobility, and was dependent on staff for transfers. Her care plan identified her as a fall risk and directed staff assistance for mobility and transfers. She also had diagnoses including COPD, asthma, CHF, spinal enthesopathy, major depressive disorder, and anxiety. Resident #12 received a heating pack to the abdomen and later developed a large blister on the left lower abdomen that was identified as a second-degree thermal burn. The record showed the heating pack was ordered for abdominal discomfort, but the TAR reflected it as given on the evening before the blister was found. Staff interviews indicated the resident had used a microwavable heating pack from outside the facility, that staff had warmed it for her, and that it had been wrapped in a towel. The facility also documented that outside hot packs were not allowed and that it did not have a policy or protocol for hot packs. The burn required ongoing wound treatment and was later documented by an outside provider as a 2nd degree thermal burn to the abdomen. Resident #12 also had an intercepted fall when she tried to go to the bathroom and transferred herself. Staff assisted her back into bed, and she later complained of left foot pain. The clinical record lacked documentation of the fall, follow-up fall assessments, vital signs, and a fall intervention. Imaging and later specialty evaluation showed a partial tear of the distal Achilles tendon and other chronic foot findings, but the record lacked documentation that the MRI was completed, lacked follow-up communication with the physician regarding the MRI results, and lacked documentation of new assessments or interventions related to the tendon tear. Resident #50 had intact cognition, required substantial to maximal assistance with mobility, and was dependent on staff for transfers. Her care plan directed one-person assistance with a walker and use of a gait belt. During a witnessed fall, a CNA assisted her from the toilet and briefly let go of the gait belt while moving the wheelchair out of the way. Resident #50 fell backward to the floor. Staff interviews confirmed the CNA let go of the gait belt and that the resident fell when her balance was lost. The administrator stated staff should not take their hands off the gait belt and should call for help or move to a safe place.
Failure to Notify LTC Ombudsman of Resident Discharges and Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of the discharge and/or transfer of 3 residents reviewed, including Residents #108, #10, and #106. Resident #108’s MDS assessment indicated discharge without an anticipated return, and the clinical census listed a discharge, but the record lacked documentation that the Ombudsman was notified of the resident’s discharge from the facility in January 2026. Resident #10 was shown in the facility EHR as discharged on 12/27/25 with a return anticipated, and the clinical census later reflected discharge and unpaid hospital leave status, but there was no documentation of Ombudsman notification for the discharge and transfer in December 2025. Resident #106 was shown in the facility EHR as discharged on 1/3/26 with a return anticipated, and the clinical census reflected hospital paid leave status on two occasions before a discharge on 1/14/26, but the record lacked documentation that the Ombudsman was notified of the discharge and transfer in January 2026 on either occasion. Staff H stated she sends the monthly Ombudsman notification list from the facility software, and acknowledged that the December 2025 and January 2026 lists did not include Residents #108, #10, and #106. The Administrator also acknowledged the lists did not include these residents and stated the facility expected the report to include all discharges and transfers, but the facility did not have a policy on notification to the LTC Ombudsman.
Medication pass error allowed a resident to ingest another resident’s medications
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice when a medication error occurred involving one resident who received medications prescribed for another resident across the hallway. Resident #102 had a BIMs score of 07, indicating moderately impaired cognition, and required partial/moderate assistance with transfers. His diagnoses included anemia, hypertension, atrial fibrillation, and cerebral infarction. During medication pass, Staff A was administering medications to multiple residents and placed another resident’s medication cup behind Resident #102’s television while holding Resident #102’s medications in hand. Resident #102 quickly grabbed the other resident’s medications and put them in his mouth before Staff A could stop him. Staff A had Resident #102 spit the medications back into the cup, and all but two pills were removed; the two swallowed medications were documented as carbidopa/levodopa ER 25-100 mg and melatonin 5 mg. Staff A then called the on-call provider with no new orders. In later interviews, Staff A stated she had prepared medications for two residents at the same time because she was running behind and intended to give Resident #102 his medications before going to the other resident’s room. Staff B, the MDS Coordinator, stated staff were expected to prepare and pass medication to one person at a time and keep eyesight on the medications. Facility policy required medication administration to follow the rights of medication management, including the right resident, right drug, right dose, right route, and right time.
Nebulizer tubing and mask not changed as expected
Penalty
Summary
The facility failed to change the nebulizer tubing and mask for a resident with intact cognition and diagnoses of moderate persistent asthma and COPD who was receiving scheduled and as-needed nebulizer treatments. The resident’s care plan stated that nebulizer equipment was to be cleaned every night per facility cleaning protocol, but it did not address how often the tubing and mask should be changed. Physician orders dated 11/26/25 included budesonide inhalation BID, Performist inhalation BID, and albuterol sulfate nebulization every 4 hours as needed for wheezing. During observation on 3/2/26 and again on 3/3/26, the resident’s nebulizer tubing was seen dated 12/17/25 while still attached to the nebulizer machine. The report stated that directions for changing the nebulizer mask or tubing could not be located in the physician orders or TAR. The ADON acknowledged that no one had changed the nebulizer tubing and mask since 12/17/25 and stated she expected staff to change them every two weeks, with the clinical coordinator responsible for the task. The Administrator later reported the facility had completed an audit of residents using nebulizers and identified a gap.
Delayed physician notification after fall and failure to follow up on MRI results
Penalty
Summary
The facility failed to notify the Primary Care Physician in a timely manner after a witnessed fall involving a resident with intact cognition, substantial to maximal assistance needs for bed mobility, and dependence on staff for all transfers. The incident report documented that the resident was found with her torso on the bed and her bottom off the bed after yelling for help, and staff assisted her back into bed. The Physician was not notified until 3 days after the incident, and the Administrator later stated the nurse did not consider the event a fall because the resident was still halfway in the bed. The facility also failed to follow up on MRI results and communicate them to the Physician who ordered the test for a resident who had gone to Podiatry for a left foot injury. The clinic note documented the Physician suspected a tendon rupture or tear and ordered an MRI, which was scheduled for the resident. The MRI results, obtained later by the MDS Coordinator, showed a mild partial-thickness tear of the distal Achilles, an old full-thickness tear of the anterior talofibular ligament, and moderate full-thickness cartilage loss of the posterior tibiotalar joint. The clinical record lacked documentation that the resident went to the MRI and lacked follow-up or communication with the Physician regarding the results. Staff stated the resident made her own appointments and got her own results, and the Administrator reported the facility did not have a policy regarding Physician notification/communication.
Repeated Medication Error Deficiency
Penalty
Summary
The facility failed to correct its own deficiency related to medication errors, which had been identified during a complaint survey in November 2025 and again during a complaint survey in December 2025. At the current recertification survey, the same concern was cited again, and the facility had a census of 102 residents at the time of the survey. The facility’s QAPI policy, dated 10/15/25, stated that the QAPI program was to be comprehensive, data-driven, and include processes for tracking and measuring performance, setting goals and thresholds, identifying and prioritizing quality deficiencies, analyzing underlying causes, developing corrective actions, and monitoring effectiveness. During an interview on 3/5/26 at 9:56 AM, the DON stated the facility had worked on medication errors and addressed them in QAPI meetings, but also acknowledged there was more work to do regarding medication errors and that repeat concerns had occurred in prior complaints and on the current survey.
Failure to Honor Resident Refusal and Maintain Dignity During Incontinence Check
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to refuse care and to be treated with dignity and respect. Resident #1, who had a BIMS score of 14 indicating intact cognition, adequate hearing and vision, and no behavior issues, required total staff assistance with toileting and hygiene and was frequently incontinent of bowel. The resident’s care plan directed staff to follow facility protocol as the resident allowed for incontinence care, to assist with toileting, and to ask yes/no questions to determine the resident’s needs. An intervention also documented that the resident preferred to be changed between 1:00 AM and 3:00 AM. On the overnight shift at approximately 2:00 AM, Staff A, a CNA, entered Resident #1’s room to perform a check and change. Resident #1 told Staff A that she was dry and did not want to be bothered. Despite this clear refusal, Staff A proceeded to check the resident by placing a hand between the resident’s thighs to feel the outside of the brief. Resident #1 reported that she was dry and that the gesture made her uncomfortable. Staff A then left without changing the resident. During the next rounds, when Staff A again attempted to check the resident, Resident #1 again stated she did not want to be bothered, and at that point Staff A stepped away and obtained the nurse. Resident #1 later reported the incident to staff, including therapy and nursing personnel, describing that Staff A had placed hands between her thighs to check the brief after she had refused care. The resident stated that she felt uncomfortable and fearful that Staff A would not respect her wishes regarding being checked and changed, and she reported having trouble sleeping related to the incident. Multiple staff interviews, including with the RN, CNA, Occupational Therapy Assistant, Social Services, and the DON, confirmed that the resident had described the same sequence of events and that Staff A acknowledged proceeding with the check despite the resident’s refusal. The facility’s own Resident Rights acknowledgement stated that residents must be cared for in a manner that promotes maintenance or enhancement of quality of life and dignity, in full recognition of individuality, which was not followed in this incident.
Failure to Document Incident Involving Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to document an incident in which a resident left the facility unattended and later returned with staff. The resident had a BIMS score of 9, indicating moderately impaired cognition, and diagnoses including hypertension, Alzheimer’s disease, non-Alzheimer’s dementia, cataracts, glaucoma, and macular degeneration. The MDS documented that the resident could understand and be understood, had no documented behaviors such as wandering or rejecting care, and was independent with personal hygiene and ambulation using a 4-wheeled walker. The care plan, however, identified the resident as an elopement risk/wanderer related to impaired safety awareness, noted that the resident wore a wander alert pendant, and was independent with mobility. Facility records showed conflicting information about the resident’s assigned household, with the Wanderguard list indicating the Life Bridges household and a resident list report indicating a different household. The DON and ADON explained that the resident lived in the Life Bridges household and had gone out the north door of the facility, where the resident was usually supervised when outside. The DON stated that because the resident did not “actually elope,” the facility decided it was not necessary to document the incident in the clinical record. Upon later review, the DON acknowledged that staff are expected to document any incidents or unusual occurrences in the clinical record for all residents. The facility’s Nurse Competency Check Off List, reviewed on 6/24/24, required documentation of follow-up notes, family communication, hot charting, changes in condition, behaviors, new skin issues, unusual events, and alleged abuse, indicating that documentation of such incidents was an expected standard that was not followed in this case.
Failure to Administer Diuretic as Ordered for Weight Gain
Penalty
Summary
The facility failed to follow a physician's order for medication administration, resulting in a resident not receiving their prescribed diuretic (Lasix) as needed when their weight increased by 3 pounds from baseline. The resident, who had diagnoses including congestive heart failure, hypertension, renal and respiratory failure, and required supervision or partial assistance with activities of daily living, was to receive Lasix 20 mg orally daily as needed for weight gain. Clinical records and the Medication Administration Record (MAR) showed that on several occasions when the resident's weight met or exceeded the threshold for administration, the medication was not given as ordered. The care plan and physician orders specifically directed staff to monitor daily weights and administer Lasix accordingly. Despite these instructions, documentation revealed that the resident's weight increased above the baseline on multiple dates without the corresponding administration of the diuretic. Staff interviews confirmed that nurses were expected to follow physician orders as written, but the review of the clinical record indicated this did not occur, resulting in the resident not receiving the medication as prescribed.
Failure to Provide Dignified and Respectful Peri-Care
Penalty
Summary
The facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of quality of life for 1 of 4 residents reviewed. Resident #1 had a BIMS score of 6, indicating severe cognitive impairment, and required staff assistance with toileting hygiene and was frequently incontinent of bowel. The resident’s diagnoses included cancer, hypertension, neurogenic bladder, and left-sided hemiplegia. The care plan identified that the resident had an ADL self-care performance deficit related to a recent brain mass and could be resistive to care due to cognition and grief, with interventions to assist with toileting, explain care before and during contact, keep routines consistent, and provide consistent caregivers when possible. The facility investigation stated that during peri-care, Staff C, CNA, was reported by Staff B, CNA, to have worked too quickly and not carefully while handling the resident. Staff B reported that the resident was rolled onto his side quickly, stated "ow" during care, and that she was holding him while peri-care was completed. Staff C stated she heard the resident say he had a hemorrhoid and did not continue wiping in that area, and she did not recall whether her hands remained on the resident when he was rolled back and placed in a new brief. The resident later stated that he did not feel safe while the activity was being performed, though he also stated it was the staff member’s job and that she did not do anything on purpose. The resident’s clinical record lacked documentation of the incident, and the Administrator verified that staff are expected to treat residents with dignity and respect at all times.
Failure to Timely Report Alleged Mistreatment Incident
Penalty
Summary
The facility failed to ensure that an alleged incident involving possible mistreatment of a resident was reported to the Department of Inspection and Appeals and Licensing within 2 hours. Resident #1 had a BIMS score of 6 indicating severe cognitive impairment, required staff dependence for toileting hygiene, was frequently incontinent of bowel, and had diagnoses including cancer, hypertension, neurogenic bladder, and left-sided hemiplegia. The care plan noted the resident was resistive to cares at times and required two staff for toileting, clear explanations before care, and a consistent routine and caregivers to reduce confusion. According to the facility investigation, a CNA reported that another CNA was working too fast and not being careful while providing peri-care to the resident. During the care, the resident said “ow,” and staff described rolling him back, cleaning stool from his buttocks, and placing a new brief. The resident later stated he did not feel safe while the activity was being performed, though he also said the aide did not do anything on purpose. The resident’s wife stated he had a hemorrhoid and dry bowel movement on the sheet, and the clinical record lacked documentation of the incident. The Administrator confirmed the facility did not notify DIAL of the incident within the required 2-hour timeframe.
Failure to Protect Resident During Peri-Care After Abuse Allegation
Penalty
Summary
The facility failed to provide a supportive and safe environment for a resident with severe cognitive impairment, dependence for toileting hygiene, frequent bowel incontinence, cancer, hypertension, neurogenic bladder, and left-sided hemiplegia. The resident’s care plan identified that he was resistive to care at times and required two staff for toileting, clear explanations during care, a consistent routine, and consistent caregivers when possible. During peri-care, staff reported that the resident said “ow” while being rolled and cleansed, and the resident later stated that he did not feel safe during the activity, although he also said the aide did not do anything on purpose. The incident began when a CNA told an RN that another CNA was working too fast and was not careful while providing peri-care to the resident. The RN notified an LPN and instructed that the CNA be kept away from the resident, but the CNA was allowed to continue working with other residents. The facility administrator later verified that the CNA should have been sent home until the investigation was completed and that the expectation was that the CNA not care for any other residents. Facility interviews described the peri-care as involving dried stool between the resident’s buttocks, use of a wet wipe to cleanse the area, and the resident stating that he had a hemorrhoid and that it hurt. The resident’s wife stated he had a hemorrhoid and dry bowel movement on his sheet, and believed the aide may have appeared harsh because she had to rub to remove stool. The facility’s abuse, neglect, and exploitation policy stated that residents must be protected from physical and psychosocial harm during and after an investigation, but staff did not treat the allegation as abuse at the time and allowed the CNA to continue working with other residents.
Failure to Administer Medications per Physician Orders Resulting in Significant Medication Errors
Penalty
Summary
A deficiency occurred when staff failed to administer medications according to physician orders for a resident with chronic kidney disease, generalized anxiety disorder, major depressive disorder, and primary insomnia. The resident required substantial assistance with mobility and was dependent on staff for transfers and toileting. The care plan and medication administration record directed staff to administer lorazepam before meals and clonazepam at bedtime for anxiety. However, review of medication records revealed that the resident received an extra dose of lorazepam at bedtime on multiple occasions and missed several doses of clonazepam at night. The medication error was identified when a Certified Medication Aide (CMA) noticed that clonazepam had only been signed out every other night, and further review showed that lorazepam was being given at night instead of clonazepam. Progress notes documented that during this period, the resident experienced increased anxiety, shakiness, insomnia, and reported not feeling well. The resident and her family expressed concerns about her condition, leading to a hospital evaluation where acute insomnia and mood changes were noted. The facility's documentation also showed that on one occasion, a dose of lorazepam was omitted in the afternoon. Interviews with staff confirmed that the CMA confused the two medications and administered them incorrectly. The nurse practitioner indicated that the resident's symptoms of increased anxiety and difficulty sleeping could be related to receiving the shorter-acting lorazepam instead of the longer-acting clonazepam at night. The facility's policy required staff to follow the five rights of medication administration, but this was not adhered to in this case, resulting in significant medication errors for the resident.
Failure to Supervise Residents with Known Sexual Behaviors
Penalty
Summary
The facility failed to provide adequate supervision to prevent sexual abuse and inappropriate contact between two residents, both of whom had documented histories of sexually inappropriate behaviors and cognitive impairments. One resident, with moderate cognitive impairment and a history of sexually inappropriate advances toward others, was care planned to require supervision at all times and interventions to prevent inappropriate interactions. Despite these documented needs, the resident was able to be alone in her room with another resident, who also had a history of sexual inappropriateness and severe cognitive impairment. Staff discovered the two residents in a compromising position, with both partially undressed and the male resident on top of the female resident. Prior to the incident, both residents had exhibited repeated sexually inappropriate behaviors, including attempts to enter other residents' rooms, inappropriate touching, and making sexual advances toward peers and staff. These behaviors were documented in clinical records and care plans, and staff were aware of the risks associated with both individuals. Staff interviews revealed that the only directive given was to attempt to keep the two residents apart, but no additional supervision or specific interventions were implemented, despite the known risks and previous incidents. Staff also reported difficulty in providing close supervision due to staffing levels and the residents' ability to move independently and quickly. The lack of clear directives and insufficient supervision allowed the two residents to be unsupervised together, resulting in the observed incident. The facility's failure to implement effective interventions and provide adequate supervision, as outlined in the residents' care plans and based on their behavioral histories, directly led to the deficiency. The administration and nursing leadership acknowledged that the facility did not provide adequate nursing supervision or specific instructions to staff to prevent such incidents, despite being aware of the residents' behaviors.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility staff failed to respond to resident call lights in a timely manner, specifically for one resident who was reviewed. This resident, identified as having moderately impaired cognition with a BIMS score of 12, required assistance with toilet hygiene and transfers due to conditions such as Alzheimer's disease, non-Alzheimer's dementia, and osteoarthritis. The resident reported that it took over 30 minutes for staff to respond to their call light, which was corroborated by the Alarm Response Report showing a response time of over 19 minutes. Interviews with facility staff, including two Certified Nursing Assistants, confirmed that it could take over 15 minutes to answer call lights, which is against the facility's expectations and state and federal regulations. The facility's administrator also confirmed the expectation for staff to respond to call lights within 15 minutes. This deficiency was identified in a facility with a census of 117 residents, highlighting a failure to provide adequate staffing to meet the needs of every resident as required.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and the use of a gait belt for Resident #6, who required substantial assistance for toilet transfers and total dependence for walking. On the morning of 4/22/24, Staff A, a CNA, assisted Resident #6 to the bathroom without using a gait belt, despite the resident's care plan specifying its necessity. As Resident #6 backed into the bathroom, her walker tipped sideways, causing her to bend at the knees and fall. This incident resulted in Resident #6 sustaining fractures to her toes and requiring a transfer to the local emergency department for further evaluation and treatment. Resident #6's Minimum Data Set (MDS) assessment indicated moderately impaired cognitive skills and a need for substantial assistance with daily activities due to conditions such as polyosteoarthritis and a recent left knee replacement. Despite the resident's request for the use of a gait belt, Staff A did not comply, citing the loss of her gait belt and not attempting to obtain a replacement. The facility's policy mandates the use of gait belts for all staff-assisted transfers, and Staff A had previously acknowledged this requirement and received training and a gait belt from the facility. The Director of Nursing (DON) confirmed that the facility provides gait belts and educates staff on their use, with replacements available at the front desk. Following the incident, the facility terminated Staff A for violating the gait belt policy. Observations and interviews with Resident #6 and staff corroborated the failure to use the gait belt, leading to the resident's fall and subsequent injuries.
Inadequate Supervision During Mealtime for Resident with Dysphagia
Penalty
Summary
The report details a critical deficiency in a nursing home setting where a resident (Resident #1) with a history of dysphagia, dementia, and stroke was not adequately supervised during meal times, leading to a tragic incident. Despite the resident's documented need for cues to slow down while eating and the presence of specific instructions in the Care Plan, the staff failed to provide the necessary supervision. This lack of oversight resulted in the resident choking on his dessert, leading to a fatal outcome. The incident highlighted a failure in the facility's supervision protocols and staff awareness of residents' individual needs, particularly in relation to mealtime safety for those with swallowing difficulties. The deficiency was exacerbated by the staff's failure to monitor Resident #1 closely during meal service, as evidenced by statements from various staff members involved in the incident. Despite clear instructions in the Care Plan and prior communication from the resident's family regarding his specific needs during meals, the staff did not provide the required level of supervision. The report indicates that the Certified Nursing Assistant (CNA) responsible for serving the resident's meal was preoccupied with other tasks and did not notice the resident choking until alerted by another staff member. This lack of attentiveness and failure to adhere to the resident's individualized care requirements contributed to the adverse outcome.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to ensure call lights were responded to in a timely manner for four residents, leading to significant delays in care. Resident #8 reported having to wait a long time for assistance to use the bathroom, resulting in her taking herself. The Alarm Response Report indicated that her call light was on for 17 minutes on one occasion and 29 minutes on another. Resident #9 expressed that she often remains in bed because there is not enough staff to transfer her to her wheelchair, and her call light was on for durations ranging from 17 to 24 minutes on multiple occasions. Resident #10's wife had to leave the unit to find help after the call light was not answered for 23 minutes, and Resident #10 was found on the ground after a fall. Resident #11 also reported delays in call light responses, with instances of waiting up to 43 minutes for assistance. The facility's policy on call light response, which mandates that call lights be answered within 15 minutes, was not adhered to. The Director of Nursing confirmed that the expectation is for all call lights to be answered within this timeframe. The documented delays in responding to call lights for Residents #8, #9, #10, and #11 indicate a failure to meet this policy, resulting in unmet needs and potential safety risks for the residents involved.
Failure to Document Critical Incident in Resident's Medical Record
Penalty
Summary
The facility failed to provide accurate resident records for one resident following their death. The clinical record for the resident, who had diagnoses of dysphagia, dementia, and a history of stroke, lacked documentation regarding a hypoxic episode that led to the resident's death. The incident occurred after the resident consumed a brownie and began coughing, showing signs of hypoxia. Despite attempts by multiple staff to perform the Heimlich maneuver, the resident did not recover, and emergency responders took over. However, the incident was not documented in the resident's electronic health record until after the survey began, two weeks later. The facility's policies on medical record documentation require that each resident's medical record contain an accurate representation of their experiences, including timely documentation of incidents. The Director of Nursing confirmed that incidents should be charted in the resident's chart. Despite these policies, the facility failed to document the critical incident in the resident's medical record, resulting in a deficiency noted by the surveyors.
Failure to Secure Controlled Substances and Maintain Medication Refrigerators
Penalty
Summary
The facility staff failed to ensure liquid Lorazepam, a controlled substance, was stored in a locked compartment in the refrigerator in two of the four medication rooms reviewed. Observations revealed that the medication refrigerators in the Lifebridge and David's Place households were unlocked, allowing access to liquid Lorazepam by nurses and certified medication assistants (CMAs). Staff interviews confirmed that the medication refrigerators were not consistently locked, and there was confusion among staff regarding the responsibility for locking the refrigerators and handling the keys. The Director of Nursing (DON) acknowledged that liquid Lorazepam and other controlled substances requiring refrigeration needed to be double locked, but issues with the medication refrigerator lock and key management were reported. Additionally, the facility failed to maintain safe operating equipment and ensure medication refrigerators were kept clean and free of ice build-up. Observations of the Lifebridge and David's Place medication refrigerators revealed a heavy build-up of ice in the freezer compartments, which contained various medications, including vaccines and antibiotics. Staff interviews indicated a lack of clarity regarding who was responsible for cleaning and defrosting the medication refrigerators. Maintenance staff reported not receiving any work orders for medication refrigerator repairs or defrosting in a long time, and there was no facility policy for medication refrigerator cleaning. The facility's failure to properly store controlled substances and maintain medication refrigerators in a clean and functional state was further highlighted by the lack of a clear policy and communication among staff. The CDC guidelines emphasize the importance of maintaining and repairing equipment to ensure the safety and efficacy of medications and vaccines. The facility's deficiencies in these areas were evident through staff interviews and observations, revealing a need for improved procedures and accountability in medication storage and equipment maintenance.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to prepare and serve all foods at a safe and palatable temperature in the Sansgaard Household, as observed during a survey. Two of ten interviewable residents reported that food temperatures were often not hot when meals were served. During an observation, Staff D, a homemaker, checked the food temperatures before serving lunch and found several items below the required 140 degrees Fahrenheit. For example, hamburger patties were at 131.5 degrees Fahrenheit, and ground beef noodles were at 110 degrees Fahrenheit. By the time the last resident was served, the temperatures had dropped further, with hamburger patties at 115 degrees Fahrenheit and fortified mashed potatoes at 108 degrees Fahrenheit. One resident reported receiving a room tray with cold soup and a not-hot grilled cheese sandwich. Staff D, who was assigned to the Sansgaard Household for the day, reported that she normally worked in another household and was unaware of where the temperature chart was kept in the Sansgaard Household. The facility's Food Temperature policy required all hot food items to be served at least at 140 degrees Fahrenheit, and if food needed reheating, it should be heated to 165 degrees Fahrenheit. The Dietician confirmed that food temperatures should be checked in the main kitchen and again before serving in the households, and any food below 140 degrees Fahrenheit should be reheated to 165 degrees Fahrenheit before serving.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as observed by state facility surveyors. On 2/28/24, Resident #91, who has severe cognitive impairment, Down Syndrome, and Obsessive-compulsive disorder, was subjected to loud and stern communication by Staff H, a Certified Medication Aide (CMA). Staff H demanded the resident go to the table to eat and made comments about the resident's sister in a frustrated tone, causing the resident to appear red, flushed, and tearful. When surveyors entered the unit, Staff H changed her tone but continued to speak loudly and sternly to the resident, further upsetting him. The resident complied with Staff H's demands but remained visibly distressed. Interviews with other staff members, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), revealed that the facility's protocol for handling resistant residents involves walking away, giving the resident time, and re-approaching them. Staff are required to complete annual dementia care training and mandatory Relias training. Despite these protocols and training, Staff H's actions did not align with the facility's expectations for treating residents with dignity and respect, leading to the observed deficiency.
Failure to Update Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with a pressure ulcer. The resident, who had severe cognitive impairment and multiple diagnoses including Parkinson's disease, major depressive disorder, dementia, chronic pain, and polyneuropathy, was totally dependent on staff for personal hygiene, toileting, bathing, and transferring. The resident was always incontinent of bowel and bladder and had a pressure-reducing device for his bed and chair. Despite these conditions, the care plan lacked a focus area related to the pressure ulcer identified on 1/23/24, which was noted to be unstageable and had been assessed and measured weekly since its discovery. The treatment for the pressure ulcer was completed as ordered, but the care plan had not been updated to include this new focus area, contrary to the facility's protocol that required a care plan intervention within 72 hours of identifying a new wound. In an interview, the MDS Coordinator confirmed that the facility's protocol was to have a care plan intervention in place within 72 hours and to put immediate interventions in place for staff to address the issue. The facility's policy on comprehensive care plans stated that the care plan would be reviewed and revised after each comprehensive and quarterly MDS, and responsible staff would be informed of the interventions identified in the care plan. However, the care plan for this resident had not been updated to include the pressure ulcer, indicating a failure to follow the established protocol and policy.
Failure to Complete Weekly Skin Assessments
Penalty
Summary
The facility failed to complete weekly skin assessments for Resident #62 as required by the resident's comprehensive, person-centered Care Plan. Resident #62, who has severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, diabetes mellitus, and non-Alzheimer's dementia, was supposed to have weekly skin inspections. However, documentation of these assessments was missing for multiple weeks in 2023 and 2024. The Care Plan, revised on 11/25/22, specifically directed staff to complete a skin inspection weekly, and an order from the resident's primary physician on 9/28/2022 also mandated a weekly Skin & Pain Assessment every Wednesday evening. Despite these directives, the electronic health records showed a lack of documentation for the specified weeks, indicating that the assessments were not completed as required. Interviews with staff, including a certified medication aide (CMA) and the Director of Nursing (DON), confirmed that the weekly skin assessments were not documented. The DON explained that the CMA had marked the treatment administration record (TAR) as completed, which did not trigger the nursing staff to complete the skin assessment report. Only nursing staff are authorized to complete these assessments, and they typically do so on the resident's first shower day of the week, which is Wednesday for Resident #62. The facility's Skin Assessment Policy, reviewed on 9/25/23, instructed staff to document the skin assessment comprehensively, but this was not adhered to in the case of Resident #62.
Deficiency in Pureed Food Preparation Process
Penalty
Summary
The facility's Dietary Staff failed to perform the proper functions of food and nutrition services for the pureed food process for seven residents requiring a pureed diet. During an observation, the cook, Staff J, did not measure the volume of pureed food after pureeing green beans, beef and noodle mixture, caramel apple dessert, and grilled cheese sandwiches. Instead, Staff J used a pre-prepared spreadsheet to determine the scoop size for each resident. Staff J also used water instead of fluids that add nutritional value, such as broth, milk, or juice, which is against the facility's puree policy and guidelines. During interviews, Staff J confirmed that she does not measure the volume of pureed food and relies on the spreadsheet for scoop sizes. The Dietician stated that kitchen staff should measure the volume after pureeing and use appropriate fluids to add nutritional value. The Dietician acknowledged that the observed process did not follow the facility's puree policy and guidelines. The facility's Puree Food Preparation Policy directs staff to measure servings before pureeing, use appropriate fluids, and measure the total volume after pureeing, which was not followed in this instance.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for Resident #91, who has Down Syndrome with intellectual disability and neurological dysfunction of the bladder requiring a suprapubic catheter. During a direct observation, Staff H was seen escorting Resident #91 back to their room with a significant length of catheter tubing dragging on the ground, which the resident stepped on multiple times. Staff H did not take any action to correct the issue. Interviews with Staff B and Staff X revealed that Resident #91 often resists catheter care and will not tolerate securing the tubing to their leg. Instead, they place the excess tubing in a dignity bag, which was not done during the observed incident.
Failure to Complete Discharge Summary and Recapitulation of Stay
Penalty
Summary
The facility failed to complete a discharge summary, including a recapitulation of stay, for one of the three discharged residents reviewed. The resident was admitted on an unspecified date and discharged on 12/5/23. The progress note documented that the resident was picked up by her advocate, and all personal items, medications, treatments, and a list of appointments were sent with her. However, the resident's electronic health record did not contain a discharge summary or a post-discharge plan of care. The Administrator confirmed that the recapitulation is done through the discharge progress note and that the facility had no interdisciplinary form or policy on recapitulation of stay.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 120 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Story City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Ames, Llc | 8.8 mi | ★★★★★ | 8 | 0 |
| Northridge Village | 9.2 mi | ★★★★★ | 4 | 0 |
| Green Hills Health Care Center | 12.7 mi | ★★★★★ | 1 | 0 |
| Rolling Green Village Care Center | 13.6 mi | ★★★★★ | 2 | 0 |
| Story Medical Senior Care | 14.7 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.