Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bethany Lutheran Home during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and chronic pain had an oxycodone/APAP order with two 30-count cards received. Staff accounts showed the narcotic count sheet was altered, signatures were written on it, and the original paperwork was discarded. One CMA said she destroyed the wrong medication after believing it was discontinued and admitted she did not complete the required checks or have a second staff member present. The medication, card, and count sheet were never found after searches of the cart, trash, shred bins, and dumpster.
A resident with severe cognitive impairment, wandering behavior, and a high wandering risk score was not adequately supervised and exited the building with visitors after a door alarm sounded. Staff did not immediately locate the resident, and the resident was later observed walking outside near a bridge and toward a busy 3-lane street. Staff interviews showed confusion about the alarm response and the facility’s door checks were inconsistent.
Infection control practices were not consistently followed during wound care, EBP care, and catheter care. Staff were observed failing to change gloves and perform hand hygiene between dirty and clean tasks, entering rooms without required gowns during high-contact care, and handling catheter equipment and wound care supplies inconsistently with facility policy. The facility also had missing water temperature and flush logs tied to its Legionella prevention program.
Delayed Call Light Response: Multiple residents with normal cognition and significant ADL assistance needs reported long waits for call lights to be answered, including waits of 30 minutes, 45 minutes, and up to 1 1/2 to 2 hours. Several residents were incontinent and dependent on staff for toileting and transfers, and one observation showed a CMA on a cell phone at the nurses’ station while an LPN directed the CMA to check on other staff. The Alarm Response Report documented repeated call light response times over 15 minutes, despite the facility’s expectation and policy requiring response within 15 minutes.
Failure to complete a significant change MDS after a resident’s decline in ADLs, mobility, and continence. A resident with heart disease and OA went from eating independently and using a stand lift to needing staff to feed her, requiring a full body lift for transfers, and becoming bladder incontinent. Staff confirmed the decline had been present for about a month, but the MDS Coordinator stated the change had not been reported and a significant change assessment should have been started.
A resident with severe cognitive impairment, hallucinations, delusions, and diagnoses including dementia, psychotic disorder, delusional disorder, and metabolic encephalopathy did not have a new PASRR completed after new mental health information was documented. The care plan addressed cognition and antipsychotic use but did not include any PASRR focus area or interventions, and staff confirmed only an older Level I PASRR was in the chart with no new PASRR submitted.
A resident with heart failure, HTN, dementia, and a psychotic disorder had an order for Furosemide and received a diuretic daily, but the care plan did not document diuretic medication use. An LPN confirmed the omission, and the DON stated diuretics should be included on the care plan when a resident is taking them.
Medications were left at the bedside for two residents without documentation of self-administration orders. One resident with COPD had nebulizer medication and equipment left on the bedside table after a treatment, and staff acknowledged the nebulizer was not cleaned and the PRN dose was left after refusal. Another resident with dementia was observed with Tums in a cup on the bedside table, and staff could not provide an order allowing bedside medication storage.
A resident with severe cognitive impairment and diagnoses including HTN, renal insufficiency, and Alzheimer's disease received another resident's medications along with the resident's own meds. Staff accounts showed an LPN and a training CMA/LPN were both involved in preparing and passing meds, resulting in the resident receiving duplicate BP medication and other wrong medications. The resident later had low BP and bradycardia, and the record showed the provider was notified and monitoring orders were obtained.
A resident with severe cognitive impairment and chronic pain did not receive scheduled morphine for 11 days after a durational order was not renewed or sent to the pharmacy following a provider review. The medication remained active on the MAR, but no new script was generated, leading to withdrawal symptoms and an ER visit. Staff interviews confirmed the lapse was due to failure to renew the order and lack of follow-up on the provider's documentation.
A resident with a history of falls and recent changes in transfer needs was transferred by only one CNA, despite the care plan requiring two-person assistance. The CNA relied on an outdated care sheet in the room, resulting in the resident sustaining a toe injury during the transfer. The incident was due to a lack of updated and accessible care plan information for staff.
A resident with no cognitive impairment was administered morphine and Ativan without consent by a nurse, despite the resident's refusal. The nurse, assisted by another staff member, justified the action as necessary for safety due to the resident's aggressive behavior. The facility's investigation confirmed the violation of the resident's rights to refuse medication and maintain dignity.
A resident with no cognitive impairment became agitated and physically aggressive, throwing objects at staff. A nurse administered medications without the resident's consent, with assistance from another staff member. The incident was not reported to management within the required timeframe, violating the facility's reporting protocol.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident, with severe cognitive impairment and on hospice care, had a care plan that did not reflect his current needs, including transfer status and catheter use. Another resident, at risk for falls, had an outdated care plan that did not address changes in transfer techniques or fall prevention measures. The absence of the staff member responsible for care plan updates contributed to these deficiencies.
A resident with no cognitive impairment, who often refused medications, exhibited confusion and aggressive behavior. Staff C, a CMA, improperly signed out medications that were administered by Staff E without the resident's consent, violating the facility's medication administration policy.
A long-term care facility failed to provide adequate nursing staff, resulting in delayed call light responses for multiple residents. One resident, frequently incontinent, experienced delays of up to an hour, while another, with a history of polio, waited 45 minutes, leading to urination in his chair. Staff cited short staffing as a reason for the delays, particularly during meal times and when shifts were understaffed.
The facility did not provide RN coverage for at least 8 consecutive hours a day for 7 days a week. The scheduled RN called in sick and walked out on consecutive days, leaving shifts unfilled. The Staff Coordinator and Administrator were aware of the situation but did not ensure coverage. The facility census was 85.
The facility failed to follow professional standards in food preparation and hand hygiene. Staff H did not perform hand hygiene before and after glove use while preparing food, and improperly checked food temperatures by piercing foil coverings. The Dining Services Manager confirmed these actions were against facility policies and CDC guidelines.
The facility failed to notify the LTC Ombudsman of a resident's hospitalization, as required. The resident was hospitalized without a signed bed hold or notification to the Ombudsman. Interviews with staff, including the DON and Social Services Director, confirmed the oversight, and the Administrator acknowledged the failure to notify.
A facility failed to provide a bed hold notice to a resident or their representative during a hospitalization period. The resident was hospitalized without receiving the required notice, as confirmed by record reviews and staff interviews. The facility's policy mandates providing a Bed Hold Notice form during such transfers, but this was not done, as acknowledged by the facility's Administrator.
The facility failed to refer two residents for a Level II PASRR evaluation despite serious mental disorders. One resident had a diagnosis of schizophrenia not included in the PASRR, and another had a diagnosis of unspecified psychosis not reflected in a new PASRR. The facility lacked a PASRR policy, relying on federal regulations.
A facility failed to address dementia care for a resident with severe cognitive impairment and multiple diagnoses, including non-Alzheimer's dementia and anxiety. The resident's care plan lacked information on dementia care, despite the facility's policy requiring individualized care plans. The DON acknowledged the oversight.
A facility failed to follow infection prevention practices during medication administration, catheter care, and wound care for three residents. A nurse poured medications into bare hands, a CNA did not perform hand hygiene or wear a gown during catheter care, and an LPN failed to perform hand hygiene and use enhanced barrier precautions during wound care. These actions were contrary to the facility's policies and infection control protocols.
A resident with a care plan requiring two-person assistance for repositioning was injured when only one CNA assisted her, resulting in a fall and a fractured femoral neck. The incident occurred due to the resident being too close to the edge of the bed and slipping off the grab bar. Staff interviews revealed a lack of awareness of the care plan requirements, and the facility's policies were reviewed.
A resident with spina bifida and other conditions fell from bed after a CNA, unaware of the care plan requiring two staff for repositioning, assisted alone. The care plan specified two staff members were needed, but the CNA believed only one was required. The DON confirmed the care plan's requirements, indicating a communication lapse in the facility.
The facility failed to treat five residents with dignity and respect, involving incidents of improper handling and communication by staff. One resident was taken to the shower room in his underwear, another was denied the use of a mechanical lift and told to urinate in his pants, and a third was verbally mistreated and told she could not walk. Additionally, two residents were observed being transported without proper covering, exposing their bodies inappropriately.
The facility failed to transfer two residents according to policy, resulting in physical harm and emotional distress. One resident was transferred using a mechanical lift by a single staff member, leading to injuries, while another resident was improperly transferred with a lift instead of a walker, causing emotional distress. Staff interviews confirmed non-compliance with the facility's policy requiring two staff members for transfers.
Missing Narcotic Medication and Altered Count Record
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a prescribed narcotic medication became missing from the facility. Resident #6 had moderate cognitive impairment with a BIMS score of 12 and diagnoses including intervertebral disk degeneration with lumbar and lower extremity pain. The resident had an order for oxycodone/acetaminophen 10/325 mg, 1 tablet by mouth twice daily, and the MAR and narcotic record showed two separate 30-count medication cards were received for the resident. The narcotic record and staff interviews showed that the medication count became inconsistent after the medication cards were handled on the medication cart. One staff member stated she received two narcotic cards for the resident and counted 60 tablets total with another nurse at shift change. Another staff member later stated she found the count sheet incorrect and reported that the count was off by a whole card of 30 tablets. The staff accounts also showed that the count sheet had been altered, with signatures written on it and the original paperwork no longer available. Staff interviews further showed that one CMA stated she destroyed the wrong narcotic medication after believing it had been discontinued in the EHR, and she admitted she did not complete the required checks before destroying it. She stated she removed the tablets, discarded the bubble pack in the medication cart trash, and placed the top of the medication card in the shred bin. Other staff stated narcotic destruction required two nursing staff present, but the medication and related paperwork for the resident were not found after searches of the carts, trash, shred bins, and dumpster. The Administrator stated the resident’s oxycodone/acetaminophen prescription had to be replaced because the medication was never found and had been removed from the facility.
Failure to Supervise Resident at Risk for Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent elopement for a resident with severe cognitive impairment and a high risk for wandering. The resident’s MDS documented a BIMS score of 5/15, diagnoses including Alzheimer’s disease, and wandering behavior. The resident also had a wandering risk assessment score of 10/16, with comments noting the resident had been wandering the halls and almost went through doors that set off alarms. The resident was independent with ambulation and had a high fall risk score on the Morse Fall Scale. On the day of the incident, the resident was taken to the main floor chapel for church without staff members present. When staff were paged to assist residents back from church, the resident was seen standing by the front door and exiting with visitors. A door alarm sounded, but the staff member who responded did not locate the resident and returned to previous duties without realizing the resident had gone outside. Later, another staff member observed the resident walking along the sidewalk outside the facility, near the bridge over a creek and heading toward a high-traffic 3-lane street with no sidewalk on that side. Staff interviews showed confusion about which alarm had sounded and whether the Wander Guard system had activated. The facility’s door logs showed weekly checks, but doors were not checked on Sundays except on the day of the elopement, and the door alarms were not checked the day before the incident. The facility’s elopement awareness protocol required door alarm checks Monday through Saturday, and the door alarm response policy required staff to immediately respond to the sounding door, scan the grounds, and account for all residents if the source was not identified.
Infection Control Lapses During Wound Care, EBP, Catheter Care, and Water Management Documentation
Penalty
Summary
The facility failed to provide appropriate infection prevention practices during resident care and failed to provide appropriate infection prevention practices for waterborne pathogens. Survey observations, record review, policy review, and staff interviews showed multiple instances where staff did not consistently use required PPE, did not perform hand hygiene at the expected times, and did not follow the facility’s own catheter and EBP procedures. For a resident with a stage 4 coccyx pressure ulcer and an order for wound cleansing and packing, a wound care nurse completed a dressing change and wound cleansing, then continued the procedure without changing gloves or performing hand hygiene before packing the wound and applying the dressing. The resident’s record documented the wound order, and the resident had no cognitive impairment on the MDS. The DON later stated hand hygiene should have been completed and gloves changed after the wound was cleansed before the new treatment and dressing were applied. For residents on Enhanced Barrier Precautions related to indwelling catheters and chronic wounds, staff were observed entering rooms and providing direct care without the expected gown and glove use during high-contact activities. One resident with an indwelling catheter and a care plan requiring gown and gloves for high-contact activities was transferred from a recliner to bed by CNAs who were not wearing gowns, and one CNA remained in the room touching linens and the call light without a gown. Another resident with an indwelling catheter was observed receiving catheter care, and although PPE was used during part of the task, the catheter bag was observed on the floor or hanging off a trash can at other times, and staff were observed handling supplies and completing the procedure with multiple PPE and hand hygiene lapses. A third resident with a stage 4 pressure ulcer and wound vac had wound care performed while staff moved in and out of the room, changed gloves inconsistently, left the room wearing a gown to obtain supplies, and did not consistently perform hand hygiene between dirty and clean tasks. The facility’s IP and DON stated EBP required gown and gloves for high-contact activities and hand hygiene with glove changes, and the facility’s policies and CDC-based guidance identified wound care, bathing, transferring, hygiene, and catheter care as high-contact activities requiring PPE use and hand hygiene. The facility also failed to maintain required water management documentation related to Legionella prevention. Review of water temperature logs showed the entire month of September was missing, and the water flush log was missing April and September entries. The Administrator acknowledged the missing logs and later stated they could not be located. The facility’s Legionella prevention plan and water flushing documentation indicated routine monitoring of water flow, temperature, and flushing at terminal ends unused for 7 days.
Delayed Call Light Response
Penalty
Summary
The facility failed to provide nursing staff to assure resident safety by not responding to call lights in a timely manner for 6 of 27 residents reviewed. The report identified repeated call light delays for residents whose records showed they needed substantial or maximal assistance with toileting hygiene, bed mobility, and transfers, and several were frequently or occasionally incontinent of bladder and/or bowel. The facility’s census was 90, and the DON and Administrator stated the expectation was that call lights would be answered in less than 15 minutes. Resident #35’s MDS showed normal cognition and frequent bladder and bowel incontinence, with substantial/maximal assistance needed for toileting hygiene, bed mobility, and transfers. The resident stated call lights sometimes took longer than 15 minutes to be answered, that staff would sometimes turn the light off and say they would return but did not, and that he had been late to activities because staff did not answer his call light. Resident #42’s MDS also showed normal cognition, frequent bladder and bowel incontinence, and substantial/maximal assistance with toileting hygiene and transfers; the resident stated it could take 45 minutes or longer for call lights to be answered and that staff sometimes left after saying they would return, resulting in incontinence episodes and discomfort. Resident #50’s MDS showed normal cognition, a stroke diagnosis, and dependence on staff for toileting and transfers; the resident stated it usually took 30 minutes for staff to answer the call light. Resident #76’s MDS showed normal cognition, occasional bladder incontinence, and substantial/maximal assistance with toileting hygiene, bed mobility, and transfers; the resident stated staff could take 1 1/2 to 2 hours to answer the call light. Observation also showed a CMA sitting at the nurses’ station on a cell phone while an LPN directed the CMA to check whether other staff needed assistance. The Alarm Response Report documented multiple call light response times over 15 minutes, including several lasting 20 minutes, 30 minutes, 39 minutes, 44 minutes, and over 1 hour, and the facility policy required response within 15 minutes.
Failure to Complete Significant Change MDS After Resident Decline
Penalty
Summary
The facility failed to complete a significant change comprehensive assessment for a resident who had a decline in condition. Resident #76’s MDS dated 7/31/25 showed diagnoses of heart disease and osteoarthritis, independence with eating, supervision or touching assistance with upper body dressing, substantial/maximal assistance with transfers, toileting, and lower body dressing, and occasional bladder incontinence. The care plan identified risks related to decline in ADLs, falls due to impaired mobility, and bladder incontinence, with interventions including assistance with dressing, toileting, and transfers. During interview and observation, the resident stated she had declined over the past month or longer, now needed staff to feed her at the assist-to-dine table, required a full body lift for transfers, and was incontinent of bladder all the time since using the full body lift. Staff observations confirmed the resident was transferred with a full body lift and required staff assistance for incontinent care and feeding. The CNA reported the resident had a big decline about a month earlier, had changed from a standup lift to a full body lift, was no longer continent of bladder, and frequently needed staff to feed her. The MDS Coordinator stated staff had not reported the decline to her, but acknowledged that the changes from independent dining to assist-to-dine, continent to incontinent, and stand lift to full lift met criteria for a significant change MDS that should have been started after 7 days. The facility policy stated the MDS assessment would be completed within 14 days of a significant change in status.
Failure to Complete PASRR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a PASRR for one resident who had new mental disorder diagnoses after admission. The resident’s MDS showed a BIMS score of 7/15 with severe cognitive impairment, hallucinations, delusions, verbal behavioral symptoms toward others, other behavioral symptoms daily, and behavior that was worse than the prior assessment. The MDS also listed diagnoses of non-Alzheimer’s dementia and psychotic disorder, and the resident was receiving antipsychotic medication. The care plan addressed impaired decision making, short-term memory impairment, poor decision making due to dementia, and antipsychotic medication use for delusional disorder and yelling out, but it did not identify any PASRR focus area or interventions. The resident’s EMR listed unspecified dementia with behavioral and psychotic disturbance and delusional disorders, and physician orders included quetiapine for delusional disorders, metabolic encephalopathy, and dementia-related diagnoses. A prior PASRR approval from 3/27/23 stated that if changes occurred or new information refuted the findings, a new screen must be completed. The EMR also included a mental health note with metabolic encephalopathy and Seroquel use. Staff in Social Services confirmed there was only a Level I PASRR in the EMR and no other PASRR documentation in the soft chart, and the Administrator stated there was no new PASRR submitted in Path Tracker and that the facility did not have a PASRR policy, but followed regulations.
Failure to Include Diuretic Use in Care Plan
Penalty
Summary
The facility failed to provide a comprehensive care plan related to high risk medications for Resident #6, who had diagnoses of heart failure, hypertension, Non-Alzheimer's dementia, and psychotic disorder. Review of the MDS showed the resident received a diuretic daily during the look-back period, and the EHR showed an order for Furosemide 20 mg, 1 tablet twice daily, starting 8/26/25. However, the resident's care plan, revised 3/12/25, contained no documentation of diuretic medication usage. During interview, an LPN stated that diuretics should be in the care plan and confirmed they were not included, and the DON stated her expectation was that diuretics would be on resident care plans if the resident was taking the medication. The facility policy stated that detailed care planning will be documented on the resident's plan of care.
Medications Left at Bedside Without Orders
Penalty
Summary
The facility failed to provide services in accordance with professional standards by leaving medications in residents’ rooms. Resident #75 had diagnoses including COPD with acute exacerbation, and the MDS dated 7/31/25 did not document a BIMS, although an EHR progress note dated 8/11/25 documented a BIMS of 15. On 9/29/25 at 10:54 AM, a nebulizer machine with clear liquid and a full vial of albuterol sulfate 0.5mg/3mg per 3 mL were observed on the resident’s bedside table. The resident stated nurses occasionally leave nebulizer medication on the bedside table for the next dose and never clean the nebulizer or mask. The MAR and EHR showed orders for ipratropium/albuterol 4 times daily and levalbuterol 0.31 mg PRN. An LPN stated she administered the PRN breathing treatment that morning, did not clean the nebulizer, and left the albuterol on the bedside table after the resident refused it; she also stated she did not think the resident had any self-administration orders. The DON stated the expectation was that the albuterol would have been returned to the medication cart if it had not been opened and the dose was refused, and that the mask should have been cleaned after use. Resident #78 had diagnoses of non-Alzheimer’s dementia and depression, and the MDS dated 8/14/25 documented a BIMS score of 12. The care plan identified short-term memory impairment and poor decision-making abilities at times, but it lacked documentation of self-administration of medications. On 9/29/25 at 1:47 PM, the resident was observed in bed with a cup containing 3 pills on the bedside table, which the resident identified as Tums and said staff leave for him to take when he wants them. An LPN confirmed the pills were Tums and said she had seen them there the day before, but she could not provide an order for medications at bedside. A CMA stated medications are to be given directly to the resident, observed until swallowed, and not left at the bedside, and confirmed the resident did not have an order to leave medications at the bedside.
Significant Medication Error Involving Wrong Resident's Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for one of four residents reviewed, involving a resident with a BIMS score of 6 and diagnoses of hypertension, renal insufficiency, and Alzheimer's disease. The resident's family member reported that the resident received another resident's medication in addition to the resident's own medications, including another resident's blood pressure medication, magnesium, Tylenol, and a fourth medication. The family member stated the resident received more than twice the normal amount of blood pressure medication and that the CMA had two cups of medications, set one resident's medications aside, and then returned to find the resident had taken the other resident's medications. Facility documentation identified that a nurse gave another resident's medication to the resident. Staff statements described that Staff D prepared the resident's medications, Staff E asked who they were for, and then Staff E administered them to the resident. Staff D then prepared another resident's medications, became confused, and later gave those medications to the resident thinking they were the resident's own. Another statement from Staff E indicated that Staff D, who was training, proceeded to give the resident another resident's medication after Staff E had already administered the resident's medications. The resident's record showed the nurse was notified of the wrong medication administration, the provider was contacted, and blood pressure monitoring was ordered every 30 minutes for the first 4 hours and then hourly for the next 24 hours. The record also showed the resident had slightly hypotensive and bradycardic vital signs later that day, and the next morning the resident's lisinopril and amlodipine were held for a blood pressure of 102/70. The DON and Administrator confirmed that Staff D was passing medications and Staff E was training her, and the facility policy required medications to be checked against the MAR and verified for the correct resident, drug, strength, dose, route, and time of administration.
Failure to Administer Scheduled Morphine Due to Lapsed Order Renewal
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and chronic pain, who was prescribed morphine sulfate 15 mg twice daily for pain management, did not receive her scheduled morphine doses for 11 days. The morphine order was a durational order requiring review every 30 days by the Nurse Practitioner. After the Nurse Practitioner’s visit and documentation to continue the morphine, the order was not renewed or sent to the pharmacy, resulting in the medication not being available for administration. The Medication Administration Record (MAR) still showed the morphine as an active order, but no new script was generated, and the pharmacy did not receive a renewal request. During the period without her scheduled morphine, the resident exhibited withdrawal symptoms and was sent to the emergency room for evaluation. Progress notes indicated that the resident experienced vomiting, diarrhea, hypertension, and nonverbal signs of pain, such as grimacing and trembling. The resident’s daughter and hospice staff later became involved, and it was discovered that the morphine order had lapsed. The resident’s condition continued to decline, and she was unable to swallow medications or food in the days leading up to her death. Interviews with facility staff revealed that the lapse in medication administration was due to a failure to renew the morphine order after the Nurse Practitioner’s review. The Assistant Director of Nursing acknowledged that the order should have been written and sent to the pharmacy, and that nurses should have noticed the absence of the order. The Director of Nursing confirmed that the resident experienced opioid withdrawal as a result of not receiving her scheduled morphine. The facility’s policy required care and services to be provided according to the most recent medical orders, which was not followed in this case.
Failure to Update and Communicate Resident Transfer Requirements Leads to Injury
Penalty
Summary
A deficiency occurred when a resident, who had a history of falls and required the assistance of two staff members for transfers following a recent fall, was transferred by only one staff member. The resident's care plan had been updated to reflect the need for two-person assistance with a gait belt after her knee gave out during a previous transfer. However, the care sheet in the resident's room incorrectly indicated that only one staff member was needed for transfers. As a result, a staff member, relying on the outdated care sheet, attempted to transfer the resident alone using a gait belt and walker, rather than following the updated care plan requirements. During this transfer, the resident sustained an injury to her fourth toe, which became bruised and later developed a blackened toenail. The staff member involved was unaware of the updated transfer requirements in the electronic care plan and used the information from the care sheet in the resident's room. The incident highlighted a failure to ensure that staff had access to and followed the most current care plan information, leading to inadequate supervision and an accident during a transfer.
Violation of Resident's Right to Refuse Medication
Penalty
Summary
The facility failed to treat a resident with dignity during medication administration. The resident, who had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was documented to have refused care such as medications at times. On the morning in question, the resident was observed to be confused and agitated, refusing medications and breakfast. The resident exhibited aggressive behavior by throwing objects at staff and was subsequently taken to her room where she continued to show signs of agitation. Staff E, a registered nurse, administered medications to the resident without her consent. Despite the resident's refusal, Staff E proceeded to give the resident morphine and Ativan, with the assistance of Staff F, who held the resident's head. Staff E justified her actions by stating she was trying to keep the resident and others safe, as the resident was exhibiting behaviors that could potentially cause harm. However, the administration of medication without the resident's consent was a violation of her rights. The facility's investigation concluded that Staff E did not allow the resident the right to refuse the medications, which was against the facility's policy. The Director of Nursing and the Administrator acknowledged that the situation could have been handled differently, suggesting that the resident needed space and time to calm down. The incident highlighted a failure to uphold the resident's rights to self-determination and dignity, as outlined in the facility's policy.
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required two-hour timeframe. The incident involved a resident with no cognitive impairment, who had a history of refusing care and medications. On the morning of the incident, the resident exhibited confusion and agitation, refusing medications and breakfast, and later became physically aggressive, throwing objects at staff and other residents. During the incident, the resident threw a cup at a nurse and another resident, and subsequently hit the nurse with another cup. The nurse, identified as Staff E, assisted the resident into a wheelchair and administered medications without the resident's consent, with the help of another staff member, Staff F, who held the resident's head. The resident was not given the option to refuse the medications, which included morphine and Ativan, despite expressing a desire not to take them due to previous hallucinations. The facility's investigation revealed that the nurse did not allow the resident the right to refuse medications and failed to report the incident to management in a timely manner. The facility's policy requires immediate reporting of such incidents to the charge nurse and the Administrator, and to the Iowa Department of Inspections and Appeals within two hours. However, the management was only informed the following day, indicating a breach in the facility's reporting protocol.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to review and revise the care plans for two residents, leading to deficiencies in their care. Resident #5, who had severe cognitive impairment and was receiving hospice care, had a care plan that did not reflect his current needs. The care plan failed to identify the resident's transfer status, positioning needs, and the presence of a catheter. Despite the resident's significant change in condition, including a hospital admission for a urinary tract infection and the initiation of hospice care, the care plan was not updated to include necessary interventions such as therapy services and reporting deterioration to the physician. Resident #6, who had normal cognition but was at risk for falls, also had an outdated care plan. The care plan did not reflect changes in the resident's transfer techniques, the use of a pressure relief cushion, or the need for enhanced barrier precautions. The resident had a history of falls, including a significant fall that resulted in a hip fracture, yet the care plan did not adequately address these risks. Observations showed that the resident was frequently left in a recliner with a sling under him, and the care plan did not include necessary interventions to prevent further falls. The deficiencies in the care plans were compounded by the absence of the staff member responsible for updating them, who was a full-time student and not present in the building. The Director of Nursing acknowledged the inaccuracies in the care plans and the need for more thorough audits and staff education. Despite the facility's efforts to improve care plan processes, the deficiencies indicate that there were still significant areas that required attention to ensure that resident needs were accurately reflected and addressed.
Improper Medication Administration to Resident
Penalty
Summary
The facility failed to adhere to professional standards in administering medications to a resident, identified as Resident #3, who had a history of refusing care and medications. The resident, with a BIMS score indicating no cognitive impairment, was diagnosed with chronic respiratory failure, atrial fibrillation, heart failure, and urine retention. On the morning of February 9, 2025, the resident exhibited confusion, agitation, and aggressive behavior, refusing medications and breakfast. Despite these behaviors, the staff did not follow proper medication administration procedures. Staff C, a Certified Medication Aide, was involved in the administration of medications to the resident. Although the resident refused medications earlier that morning, Staff C drew up morphine and provided the Ativan bottle to Staff E, who administered the medications without the resident's consent. Staff C signed out the medications as given, despite not being present during administration. This action was contrary to the facility's medication administration policy, which requires the staff administering the medication to document its administration and ensure the resident has taken it. The Director of Nursing confirmed that Staff C acknowledged her mistake and was educated on the proper procedure. Staff E admitted to medicating the resident without giving her a choice, citing the resident's dangerous behavior as justification. The facility's policy mandates that medications be administered per physician order and documented by the administering staff, which was not followed in this instance, leading to the deficiency.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Multiple residents reported significant delays in call light responses, with some waiting up to 59 minutes. Resident #54, who is frequently incontinent, experienced delays of up to an hour, impacting her ability to use the restroom and attend breakfast. The facility's alarm response report confirmed numerous instances where call light response times exceeded 15 minutes, with some delays lasting over 45 minutes. Resident #22, who requires assistance for toileting and has a history of polio, reported a 45-minute delay in call light response, resulting in urination in his chair. His care plan highlights a risk for injury due to his medical conditions, yet the facility's call light log showed multiple instances of delayed responses. Staff interviews revealed that short staffing frequently led to extended call light response times, particularly during meal times and when shifts were understaffed. Resident #289, admitted recently, also experienced delays in call light responses, with times exceeding 15 minutes on several occasions. This resident requires substantial assistance for transfers and has a fracture, emphasizing the need for timely staff response. Similarly, Resident #10, who is dependent on assistance for transfers and has end-stage renal disease, was observed without access to a call light, further highlighting the facility's failure to ensure resident safety. Staff acknowledged the delays, attributing them to staffing shortages and the need to manage residents with behavioral issues.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 7 days a week, as required by regulations. The deficiency occurred when the scheduled RN called in sick after being at work for less than 30 minutes on one day and walked out on the next day after looking at the schedule. The Staff Coordinator was aware of the situation but did not fill the position with another RN for the empty shifts. The Administrator, along with the Nurse Consultant, acknowledged the lack of RN coverage on these days, although the Administrator was not initially aware of the call-in on the first day. The facility census was 85 at the time of the deficiency.
Failure to Follow Food Safety and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to professional standards in food preparation, serving, and distribution, as observed during a survey. Staff H, a cook, was seen modifying an entree to a mechanical soft consistency without performing hand hygiene before donning a glove. Staff H used a gloved hand to handle the turkey and a non-gloved hand to operate the food processor, then compacted the turkey in a measuring cup with the gloved hand. After completing the task, Staff H removed the glove and disposed of it without performing hand hygiene before covering the food and placing it in the steam oven. Further observations revealed that Staff H did not consistently follow proper procedures when checking food temperatures, as they stabbed a thermometer through the aluminum foil covering the food, creating large holes. Additionally, during the preparation of buttered bread, Staff H used a single glove on one hand and did not perform hand hygiene before glove application. The Dining Services Manager confirmed that staff should not touch other items when using a gloved hand for food management and emphasized the importance of hand hygiene immediately after glove removal. The facility's policies and procedures, as well as CDC guidelines, were not followed, contributing to the deficiency.
Failure to Notify LTC Ombudsman of Resident's Hospitalization
Penalty
Summary
The facility failed to notify the Long-Term Care (LTC) Ombudsman of a resident's transfer to the hospital, which was identified during a clinical record review and staff interviews. Specifically, the facility did not provide notification for one of the six residents reviewed, who was hospitalized from June 2 to June 10, 2024. The facility's document, Notice of Transfer Form to LTC Ombudsman, for June 2024, lacked the required notice of this resident's hospitalization. Interviews with facility staff revealed that the Director of Nursing (DON) indicated that Social Services typically handled bed holds and notifications to the LTC Ombudsman, and the document should have been in the resident's chart. However, the Social Services Director confirmed that there was no signed bed hold or notification to the LTC Ombudsman for the resident's hospital admission. The Administrator acknowledged the oversight, confirming that the facility did not perform the necessary notification for the resident's hospitalization.
Failure to Provide Bed Hold Notice During Hospitalization
Penalty
Summary
The facility failed to provide a bed hold notice to a resident, the resident's representative, or the Power of Attorney (POA) during a hospitalization period. Specifically, Resident #26 was hospitalized from June 2, 2024, to June 10, 2024, without receiving a bed hold notice, as confirmed by a review of the resident's electronic and paper clinical records. Interviews with the Director of Nursing (DON) and the Social Services Director revealed that the responsibility for handling bed holds and notifying the LTC Ombudsman typically fell to Social Services, but in this case, the necessary documentation was not completed. The facility's Bed Hold Policy, dated March 9, 2019, requires that a Bed Hold Notice form be provided to the resident or their representative when a resident is transferred to a hospital or goes on therapeutic leave. However, this procedure was not followed for Resident #26, as acknowledged by the facility's Administrator.
Failure to Refer Residents for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer two residents for a Level II Preadmission Screening and Resident Review (PASRR) evaluation despite the presence of serious mental disorders. Resident #16 had a Minimum Data Set (MDS) assessment indicating severely impaired cognition and a diagnosis of schizophrenia, which was not included in the Level I PASRR screening. The facility's administrator acknowledged that the diagnosis of schizophrenia should have been identified and included in the PASRR since 2020. Additionally, the facility lacked a policy related to PASRR, relying instead on federal regulations. Resident #36's MDS assessment showed moderately impaired cognitive skills and diagnoses of anxiety disorder, psychotic disorder, and Parkinsonism. Despite these findings, the PASRR Level I Screen Outcome did not indicate a need for PASRR intervention. The resident's medical records revealed a diagnosis of unspecified psychosis not due to a substance or known physiological condition, which occurred during their stay. The Director of Nursing and Social Services Director confirmed that a new PASRR was not completed to reflect this additional diagnosis. The facility did not have a PASRR policy but stated they followed federal regulations.
Failure to Address Dementia Care in Resident's Care Plan
Penalty
Summary
The facility failed to address dementia care for a resident diagnosed with non-Alzheimer's dementia, stroke, seizure disorder, mild dementia without behavioral, psychotic or mood disturbance, and anxiety. The resident's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 5, reflecting severely impaired cognition. Despite these diagnoses, the resident's care plan, revised on 10/21/24, lacked information regarding dementia care. The facility's Comprehensive Care Plan policy, revised on 7/18/22, mandates that care, treatment, and services be individualized to the resident's needs, including a comprehensive plan of care with measurable objectives and timetables. However, the facility did not adhere to this policy for the resident in question. During an interview, the Director of Nursing acknowledged that the facility should have addressed the resident's dementia in the care plan.
Infection Control Deficiencies in Medication and Personal Care
Penalty
Summary
The facility failed to adhere to proper infection prevention practices during medication administration, personal care, catheter care, and wound care for three residents. For Resident #22, a registered nurse was observed pouring medications directly from stock bottles into his bare hands before placing them into a medication cup, contrary to the facility's policy which requires using the cap of the stock medication or directly into the medication cup. This action was not in line with the expected infection control practices as outlined by the Director of Nursing (DON). Resident #58, who used a urinary indwelling catheter, received catheter care from a certified nursing assistant (CNA) who did not follow proper hand hygiene protocols. The CNA changed gloves multiple times without performing hand hygiene and failed to wear a gown as required by the facility's transmission-based precaution policy. The DON acknowledged these lapses in infection control, noting the absence of enhanced barrier precautions and the failure to perform hand hygiene before leaving the resident's room. For Resident #1, who had a new Stage II pressure ulcer, a licensed practical nurse (LPN) did not perform hand hygiene between glove changes during wound care. The LPN also failed to wear a gown, despite the presence of an enhanced barrier precaution sign outside the resident's room. The DON confirmed that staff should perform hand hygiene between glove changes and use enhanced barrier precautions when dealing with open wounds, indicating a breach in the facility's infection control protocols.
Failure to Provide Adequate Assistance During Repositioning
Penalty
Summary
The facility failed to prevent an accident involving a resident who required assistance with repositioning in bed. The resident, who had a care plan indicating the need for two staff members to assist with repositioning, was assisted by only one Certified Nursing Assistant (CNA) when she rolled out of bed and sustained injuries. The resident, who had a Brief Interview of Mental Status (BIMS) score of 14 indicating no cognitive impairment, suffered a closed displaced fracture of her left femoral neck, requiring surgical repair. The incident occurred when the resident requested to be repositioned in bed. Despite the care plan's requirement for two-person assistance, only one CNA was present to assist the resident. During the repositioning, the resident slipped off the grab bar and fell to the floor, resulting in significant injuries. The facility's investigation noted that the resident was too close to the edge of the air mattress, which may have shifted during the repositioning, contributing to the fall. Interviews with staff revealed that some were unaware of the care plan's requirement for two-person assistance, and others preferred to have additional help to prevent injury. The Director of Nursing acknowledged that the care plan required two staff members for repositioning and that the CNA should not have assisted the resident alone. The facility's policies on comprehensive care plans and ADL services were reviewed, highlighting the need for individualized care plans appropriate to residents' needs.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the care plan for a resident who required total assistance from two staff members for repositioning in bed. The resident, who had a BIMS score indicating no cognitive impairment, was diagnosed with spina bifida, seizure disorder, anxiety, opioid use, insomnia, and chronic pain syndrome. The care plan, revised in July 2024, specified the need for two staff members to assist with repositioning, utilizing bilateral grab bars. However, on a night in July 2024, the resident activated the call light for assistance, and a CNA responded alone, helping the resident roll to the right side. This action resulted in the resident being too close to the edge of the bed and subsequently falling onto the floor. The Director of Nursing acknowledged that the care plan required two staff members for repositioning, but the CNA involved was unaware of this requirement. The CNA stated that she had been informed that the resident required assistance from only one staff member. The facility's policy on comprehensive care plans, revised in July 2022, mandates individualized, interdisciplinary plans appropriate to each resident's needs. The failure to follow the care plan as documented led to the resident's fall, highlighting a breakdown in communication and adherence to established protocols.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat five residents with dignity and respect, as evidenced by multiple incidents involving improper handling and communication by staff. Resident #2, who had no cognitive impairment, reported being taken to the shower room in his underwear without any covering. This was corroborated by another resident who witnessed the incident and reported it to the Director of Nursing (DON). Despite the resident's military background and lack of personal discomfort, the DON acknowledged that such actions were inappropriate and assured it would not happen again. Resident #5, who also had no cognitive impairment and used a wheelchair, experienced neglect and rough handling by a staff member. The resident needed assistance to use the restroom and was denied the use of a mechanical lift, which he had been using for a year. The staff member shoved him back into his chair and told him to urinate in his pants, leading to the resident soiling himself. The DON confirmed that the staff member did not follow the facility's policy of having two staff members present when using a mechanical lift and that the lift was functional when checked by other staff. Resident #6, who had no cognitive impairment and used a wheelchair, was subjected to verbal mistreatment by a staff member who insisted she could not walk, despite the resident's protests and a sign indicating she required assistance with a gait belt. The resident felt helpless and worthless due to the staff member's behavior. Additionally, Resident #7 and Resident #8 were observed being transported to and from the shower room without proper covering, exposing their bodies inappropriately. The Assistant Director of Nursing (ADON) acknowledged ongoing issues with staff not adequately covering residents during transfers and emphasized the need for complete coverage with bath blankets.
Improper Transfer Procedures
Penalty
Summary
The facility failed to transfer two residents in a manner that prevented accidents and hazards. Resident #5, who had a BIMS score of 13 and used a wheelchair, was transferred using a mechanical lift by a single staff member, contrary to the facility's policy requiring two staff members. During one such transfer, the mechanical lift stopped working, and the resident was left in a recliner. The resident reported hitting his hands on the metal frame of the bathroom entrance during these transfers. Staff interviews confirmed that the policy was not followed, and the staff member involved was aware of the requirement for two staff members but chose to proceed alone due to difficulty finding assistance. The Director of Nursing (DON) and other staff members corroborated these findings, noting that the staff member had received training but failed to adhere to the policy consistently. The resident expressed distress over the incident, and the staff member was subsequently suspended for not following the policy. Another staff member also admitted to performing transfers alone when unable to find help, further highlighting the issue of non-compliance with the facility's policy. Resident #6, who had a BIMS score of 15 and used a wheelchair, was also not transferred according to the care plan. The care plan required two staff members to assist with transfers using a walker, but a staff member attempted to use a mechanical lift instead. The resident objected, stating she could walk short distances with a walker, but the staff member insisted on using the lift, leading to a confrontation. The resident felt helpless and worthless as a result of the incident. The DON and other staff members confirmed that the policy required two staff members for transfers and that the staff member involved had been educated on the proper procedures. Despite this, the staff member chose to use the lift alone, citing previous difficulties with the resident's mobility. The facility's policy, as outlined in the Lifting and Transferring Orientation Guide for Nurses and CNAs, mandates that all nursing staff be oriented to lifting and transferring techniques upon hire and that the use of any mechanical lift requires at least two staff members. The facility's failure to adhere to this policy resulted in improper transfers for both residents, leading to physical harm and emotional distress. Staff interviews and documentation revealed a pattern of non-compliance with the policy, despite repeated training and education efforts by the facility.
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What surveyors actually found near you
We read the 383 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Council Bluffs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Gate | 0.8 mi | — | 0 | 0 |
| Prairie Gate | 0.8 mi | — | 0 | 0 |
| Prairie Gate | 0.8 mi | ★★★★★ | 3 | 0 |
| North Crest Living Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Midlands Living Center L L C | 1.6 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.