Bishop Drumm Retirement Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Johnston, Iowa.
- Location
- 5837 Winwood Drive, Johnston, Iowa 50131
- CMS Provider Number
- 165448
- Inspections on file
- 33
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Bishop Drumm Retirement Center during CMS and state inspections, most recent first.
Surveyors found that inadequate staffing led to prolonged call-light response times, closure of a dining room due to low staffing, and the DON working as a charge nurse despite a high census. Continuous observation showed a resident repeatedly using the call light for about an hour while staff briefly entered the room, turned off the light, and left without addressing her request for a bath. Multiple residents with intact or moderately impaired cognition reported waiting 30 minutes to several hours for help, especially at night and on weekends, including long waits for incontinence care and assistance from the toilet, and reported seeing staff sleeping on duty. Staff interviews confirmed frequent short staffing, particularly on nights and weekends, frequent call-ins, reports of staff sleeping, and that the DON had been working the floor to cover open shifts, contrary to regulatory limits. Resident Council minutes documented ongoing complaints about missed showers, lack of fresh water, staff cell phone use, and long call-light times.
The facility failed to prevent the DON from serving as a charge nurse when the average daily census exceeded 60 residents. Multiple RNs and CNAs reported that, due to staffing shortages, the DON regularly worked nights and overnight shifts on the floor in a charge nurse role, including shortly before going on maternity leave. Staffing logs confirmed specific dates when the DON functioned as a floor nurse. The Assistant Executive Director acknowledged that the DON had been used as a charge nurse despite knowing this was not permitted, and no relevant policy was available for review.
The facility was cited for failing to implement an effective QAPI/QAA process to correct ongoing insufficient nursing staff deficiencies. State survey records showed multiple prior surveys over about two years with repeated staffing-related citations, culminating in a fifth Insufficient Nursing Staff deficiency. Although the facility’s QAPI plan identified staff retention as an improvement focus and described a process for identifying issues, leadership reported that no Performance Improvement Plan (PIP) addressing staffing was in place at the time of the survey.
Surveyors identified multiple infection control failures, including a resident with an indwelling catheter whose drainage tubing was repeatedly observed resting on a trashcan, with staff giving conflicting statements about whether this practice was acceptable. A housekeeper was seen using a cart repaired with partially detached duct tape, leaving exposed adhesive surfaces that could harbor contaminants. In addition, an in-home nurse performed wound care on a cognitively impaired resident with chronic conditions and a right foot ulcer under EBP without donning a required gown, despite posted EBP instructions and an active order, and then used the same gloved hands to handle the resident’s drinking cup.
Surveyors found that an LPN failed to follow safe medication practices for multiple residents, including not priming a newly attached insulin pen needle before injection, using insulin pens that lacked documented open dates, and directing a CMA to administer PRN acetaminophen for fever when the existing order was only for mild pain and on hold. These actions involved residents with diabetes and other chronic conditions who were receiving insulin injections with FlexPens and one resident who was lethargic with an elevated temperature, leading to attempts to administer medication without a corresponding physician order for that indication.
A resident with moderately impaired cognition and multiple diagnoses became lethargic and semi-responsive, with a temperature of 100.4°F. An LPN directed a CMA to obtain vital signs and administer Tylenol, which the resident refused, and a CNA was instructed to return the resident to her room. A progress note documented the semi-responsive state, fever, and refusal of Tylenol, but the subsequent change-in-condition evaluation recorded family and provider notification at a time when the LPN reported being away at lunch. This resulted in documentation that did not accurately reflect the timing of events, contrary to facility policy requiring complete, accurate, and timely medical records.
A resident with CAD, DM, depression, and generalized weakness, who required substantial assistance with personal hygiene, had a care plan specifying daily hair brushing and daily shaving. Despite this, the resident was observed with a long beard and matted, unwashed hair and reported repeatedly asking staff to shave her, being told they could not do so because of her diabetes and that only a barber or nurse could shave her. Facility records showed no refusals of bathing or personal care and documented daily bathing with extensive assistance, while staff interviews revealed uncertainty about whether CNAs could shave a diabetic resident and reports that grooming requests, including beard trimming, were not consistently honored, contrary to facility expectations and policy requiring documentation of refusals.
A resident with moderately impaired cognition and multiple medical conditions became lethargic at the dining table, required repeated tactile stimulation to respond, and was found to have a temperature of 100.4°F. An LPN directed staff to obtain vitals and attempt Tylenol administration, which the resident refused, and then had the resident returned to her room. Documentation showed the resident was semi-responsive with a fever and refusal of Tylenol, but the LPN left for lunch without promptly notifying another nurse, the provider, or the resident’s family, despite staff acknowledging that this represented a change in condition requiring immediate provider and family notification and completion of an electronic change-in-condition form, as required by facility policy.
A resident with moderately impaired cognition, diabetes, partial paralysis, and non-traumatic brain dysfunction became lethargic and semi-responsive, requiring repeated tactile stimulation to arouse, and was found to have a temperature of 100.4°F. An LPN requested vital signs, instructed a CMA to give Tylenol (which the resident refused twice), and then had a CNA return the resident to the room before leaving the unit for lunch without notifying a provider or arranging further monitoring. Documentation noted the semi-responsive state, fever, and refusal of Tylenol, but an eINTERACT change-in-condition evaluation lacked interventions and there were no follow-up assessments. Other nursing staff stated that such findings represented a significant change in condition requiring provider notification and ongoing assessment, and the resident’s care plan and facility policies did not address staff directives for mental status changes.
A resident with moderately impaired cognition, partial paralysis, and extensive mobility assistance needs was transported in a wheelchair without foot pedals by an LPN, despite staff acknowledging that wheelchair foot pedals should always be used during transport unless the resident is self-propelling. The resident, who was lethargic at the time and required repeated stimulation to respond, was moved from the dining room to a hallway area, and later interviews with nursing staff and the ADON confirmed this practice was inconsistent with their expectations. The facility lacked a written policy providing directives for safe wheelchair transport.
A resident with severe cognitive impairment and multiple health conditions developed an unstageable pressure ulcer on the left heel, but the care plan did not address this wound or include interventions such as repositioning or heel floating. Clinical records showed repeated failures to assess, document, and treat the ulcer, with wound care not initiated until weeks after identification. Facility staff and documentation confirmed that required interventions for pressure ulcer prevention and management were not consistently implemented or recorded.
The facility experienced ongoing deficiencies in pressure sore management, professional standards of care, nursing staffing, and infection control, as evidenced by repeated citations over multiple surveys. Despite having a QAPI plan and implementing various tracking and auditing measures, the same issues continued to recur, indicating that the facility's quality assurance processes were not effective in preventing or correcting these problems.
A resident with multiple medical devices and wounds did not receive care in accordance with Enhanced Barrier Precautions, as staff failed to consistently use gowns and gloves during high-contact care and did not perform hand hygiene or change gloves between dressing changes, contrary to facility policy.
A nurse failed to change gloves between wound and suprapubic catheter care for a resident with complex medical needs, and did not use proper technique when cleaning the catheter site. This improper care was followed by the resident developing a urinary tract infection, as confirmed by lab results.
A resident with a g-tube and multiple complex medical conditions did not receive required water flushes before and after medication administration, as a nurse administered medications through the g-tube without following facility policy for flushing. The nurse used an unspecified amount of water and did not adhere to the protocol, which was confirmed by the DON.
Surveyors found that staff did not consistently respond to call lights within the facility's 15-minute standard, with some residents reporting waits of up to 40 minutes, especially at night. Two residents with significant physical and cognitive impairments were observed without call lights within reach for extended periods, despite multiple staff being present in their rooms. Facility policy requires call lights to be accessible, but this was not consistently followed.
A resident with severe cognitive impairment and multiple medical conditions experienced significant weight loss over several months, prompting dietary recommendations to adjust tube feeding. However, there was no documentation that the family or emergency contact was notified of these changes, despite facility policy requiring such notification. The DON confirmed that conversations with the family were not documented.
The facility did not consistently obtain weekly weights as ordered for three residents with feeding tubes, all of whom had complex medical conditions requiring close nutritional monitoring. Despite care plans and physician orders specifying regular weight checks, documentation showed missed or infrequent weights, and staff interviews confirmed ongoing issues with equipment and adherence to protocols. This failure to follow professional standards resulted in inadequate monitoring of residents' nutritional status.
Surveyors found that several room doors could not be closed, a board for a window sill remained on the floor for over a month, a bathroom call light was not working, and an electrical outlet sparked when used, despite residents and staff reporting these issues. Work orders were not consistently open or active for these problems, and maintenance requests were not addressed in a timely manner, resulting in an environment that was not safe, clean, or homelike.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
Residents and family members reported significant delays in call light responses, with some waiting 20 to 50 minutes for assistance. Multiple cognitively intact residents and a family member confirmed these delays, and Resident Council Minutes documented ongoing concerns. The DON acknowledged the expectation for responses within 15 minutes, but the facility did not consistently meet this standard.
Staff did not adhere to infection control protocols for two residents with medical devices. One resident with a feeding tube received care from staff who failed to perform hand hygiene between glove changes and did not sanitize equipment or change gloves as required by EBP. Another resident with a catheter had their catheter bag observed on the floor with the drain port touching the ground on multiple occasions. The DON confirmed these practices did not meet facility policy.
A resident with diabetes, stroke, and aphasia experienced persistently high blood glucose and elevated heart rate over several days without timely provider notification or additional insulin administration. Nursing documentation was lacking, and staff did not escalate care until the resident's condition became critical, resulting in hospitalization for DKA, sepsis, and pneumonia.
A resident with severe cognitive impairment and a history of falls, who required substantial assistance with transfers and toileting, was left to ambulate independently from the bathroom, resulting in a fall and injury. Staff were inconsistent in following the care plan, and there was confusion regarding the resident's required level of assistance. The care plan was not updated to reflect the resident's current needs, and staff did not provide the supervision necessary to prevent the accident.
The facility failed to perform and document required post-dialysis assessments and follow-up for missed medications for a resident with complex medical needs, resulting in a hospital transfer for abnormal vital signs and lethargy. Additionally, the facility did not document a post-fall assessment within 24 hours for another resident after a witnessed fall, with required information only entered as a late entry the next day.
Two residents dependent on staff for transfers did not receive adequate supervision or proper use of assistance devices. One was transferred using improper technique, with staff lifting by the pants instead of solely using a gait belt, contrary to the care plan. Another was injured when a CNA used a sit-to-stand lift instead of a full body lift and failed to provide the required two-person assistance. Additionally, a sit-to-stand lift in use was found to have damaged handles with exposed metal, in violation of facility policy.
Multiple residents experienced significant delays in call light response and assistance with care needs, with some waiting up to 40 minutes for staff to respond. Residents dependent on staff for mobility, toileting, and personal care were left unattended or in soiled clothing for extended periods, and staff attributed these delays to short staffing. These actions were inconsistent with the facility's policy requiring call lights to be answered within 15 minutes.
Two residents reported ongoing mouse activity in their rooms, with one resident experiencing the issue for several months and another noting a mouse living in his closet. Staff interviews confirmed that complaints were made, but the pest control company had not been notified or conducted inspections for mice. Observations revealed mouse droppings and structural gaps at an exit door, contributing to the deficiency in pest control.
A resident experienced significant weight loss due to the facility's failure to provide adequate nutritional interventions. Despite the resident's preference for Bosnian food and a care plan intervention to provide Glucerna, no additional measures were taken to address the weight loss. Meals were not individualized, and the resident often slept through meal times, leaving food untouched. The facility's policies on nutritional management were not adequately followed, resulting in a lack of timely interventions.
The facility failed to implement proper infection control practices, as observed in multiple instances. CNAs improperly positioned a resident's catheter bag, and a CMA entered a resident's room on contact isolation without PPE or hand hygiene. Additional observations revealed staff failing to perform hand hygiene before and after tasks, contrary to facility policies.
The facility did not secure Electronic Health Record information for 16 residents. A report sheet with 21 residents' information was found face up on a medication cart, contrary to the facility's confidentiality policy. The DON confirmed that the information should have been kept under a binder.
A facility failed to maintain resident dignity when two staff members argued loudly in front of nine residents in the dining room. Additionally, a CNA charting monitor was left open and unattended, compromising resident confidentiality. The Executive Director acknowledged that monitors should be locked when not in use to protect privacy.
A resident with existing Stage IV pressure ulcer and comorbidities developed a second Stage IV ulcer due to the facility's failure to provide consistent repositioning and wound care. The care plan lacked a specific repositioning schedule, and there were gaps in treatment documentation, leading to the resident's hospitalization.
Two residents at an LTC facility developed pressure ulcers due to inadequate care and interventions. One resident, with a history of septicemia and dementia, developed unstageable deep tissue injuries on both heels and a skin tear on the buttock, leading to hospitalization for septic shock. Another resident, with a history of stroke and diabetes, developed a Stage IV pressure ulcer on the sacrum, resulting in a hospital transfer and subsequent death. Staff interviews revealed systemic issues, including inadequate staffing, contributing to delays in repositioning and care.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights and unmet resident care needs. Observations and interviews revealed that residents often waited up to two hours for assistance, with administrative staff stepping in to help during state surveys. Staffing levels were insufficient, particularly on the night shift, leading to issues such as delayed repositioning, increased skin problems, and weight loss among residents. Despite a policy for timely call light response, the facility's practice did not meet these standards.
The facility failed to maintain an effective QA program, resulting in repeated deficiencies, including F725 and F686, as identified in surveys and complaint investigations. Despite implementing a QAPI change process, systemic issues persisted, and the new Administrator acknowledged the need for improvement, particularly in areas affecting the facility's 5-Star Rating Scale, such as pressure ulcers.
A resident with severe cognitive impairment and incontinence was observed sitting in the commons area with her adult brief exposed on two occasions. Staff acknowledged the issue but did not consistently ensure the resident was covered, contrary to the facility's dignity policy.
The facility failed to initiate physician's orders for two residents, leading to deficiencies in their care. One resident did not receive recommended wound care, and another experienced seizures due to delayed medication administration.
A resident with severe cognitive impairment and total dependence on staff for personal hygiene was observed in a state of neglect, with unkempt hair and exposed adult brief, due to inconsistent care and staffing issues. Staff interviews and observations revealed failures in adhering to the facility's grooming and dignity policies.
Inadequate Staffing Leading to Prolonged Call-Light Delays and DON Working as Charge Nurse
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nursing staff on a daily basis to meet resident needs and to ensure appropriate licensed nurse coverage on each shift. Surveyors documented prolonged call-light response times, closure of a dining room due to low staffing, reports of staff sleeping while on duty, and the DON functioning as a charge nurse despite a census over 60 residents. The facility census was 124. Multiple residents with varying levels of cognition, as measured by BIMS scores ranging from moderate impairment to fully intact cognition, reported frequent and extended delays in receiving assistance, particularly during nights and weekends. Direct observation on one evening showed a resident’s call light in a specific room being activated repeatedly over more than an hour, with staff entering the room briefly several times, turning off the call light, and leaving within seconds without addressing the resident’s needs. When interviewed, the resident in that room stated that staff had not addressed her request for a bath or bed bath and that she had been using her call light for about an hour without receiving help or an explanation. She reported that staff entered only to turn off the call light without speaking to her and expressed frustration with this pattern. Resident Council minutes over several months documented repeated concerns about missed showers/baths, lack of fresh water, staff using cell phones while on duty, and long call-light response times. Multiple residents reported that call-light response times were frequently 30 minutes to several hours, with nights and weekends identified as the worst periods. Several residents described waiting one to three hours for assistance with changing soiled incontinence briefs or getting off the toilet, and two residents reported that the North East dining room was closed on a recent weekend due to insufficient staff, resulting in residents being required to eat in their rooms. Residents also reported directly observing staff members sleeping on the job, including specific times and locations, and stated they had repeatedly reported these issues to administration and through Resident Council without perceiving improvement. Staff interviews corroborated that staffing was often inadequate, especially on nights and weekends, that call-light response could take hours, and that call-ins were frequent. Staff members, including CNAs and RNs, reported working short-handed once or twice a week or more, particularly on overnight and weekend shifts, and stated that the DON had been working the floor to cover open shifts. Review of staffing records confirmed that the DON worked the floor on at least two dates, despite regulations prohibiting the DON from serving as a charge nurse when the average daily census exceeds 60 residents. Several staff and residents reported staff sleeping on duty or appearing to sleep at the nurses’ station, and some staff stated they had reported these incidents to the DON. The facility’s Rules of Conduct policy identified sleeping or giving the appearance of sleeping on the job as an unsatisfactory behavior warranting termination. The ADON stated that staff were prohibited from sleeping on the job and that the expectation was for call lights to be answered within 15 minutes, but the observed and reported delays and staffing practices demonstrated that this expectation was not being met.
DON Inappropriately Used as Charge Nurse When Census Exceeded 60
Penalty
Summary
The deficiency involves the facility’s failure to prevent the Director of Nursing (DON) from serving as a charge nurse despite a reported census of 124 residents, which exceeds the regulatory threshold of 60 residents. Multiple staff interviews on 02/12/2026 confirmed that the facility was understaffed and that the DON had been working nights and overnight shifts on the floor in a charge nurse role to cover staffing shortages. Staff P, an RN, stated the facility was understaffed and that the DON was serving as a charge nurse. Staff Q, an RN, reported that the DON had been working as a charge nurse alongside the Assistant Executive Director and other nursing leadership to address staffing shortfalls and that the DON was working the floor the week she left for maternity leave. Additional staff corroborated that the DON had been functioning as a floor nurse. Staff R, a CNA, confirmed the DON had been working the floor as a nurse leading up to her maternity leave due to staffing shortages. Staff L, a CNA, similarly confirmed that the DON was working the floor in a nurse leadership capacity and stated this last occurred in January. Review of the last 30 days of staffing logs showed the DON worked as a floor nurse on 01/11/2026 and 01/21/2026. In an interview, the Assistant Executive Director confirmed the DON had been serving as a charge nurse on the floor and acknowledged awareness that this was prohibited. A policy addressing this issue was unavailable for review.
Repeated Staffing Deficiencies Not Addressed Through QAPI/PIP
Penalty
Summary
The deficiency involves the facility’s failure to ensure an effective QAPI/QAA process to address previously identified quality deficiencies related to insufficient nursing staff. Review of the State Survey Agency’s public website showed that the facility had been cited for staffing deficiencies on four separate surveys within a roughly two-year period, with survey end dates of 06/27/2024, 04/03/2025, 07/21/2025, and 09/17/2025, resulting in an Insufficient Nursing Staff deficiency for the fifth time in that timeframe. The facility’s QAPI plan, created on 02/26/2025, outlined how the QAPI team would identify issues and specifically listed staff retention as a QAPI improvement focus. However, during an interview with the Executive Director and Assistant Executive Director, they acknowledged that the QAPI plan did not currently include a Performance Improvement Plan (PIP) related to staffing, despite the repeated staffing-related deficiencies identified by surveyors.
Infection Control Failures in Catheter Care, Equipment Maintenance, and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to indwelling catheter management, equipment maintenance, and adherence to Enhanced Barrier Precautions (EBP). Surveyors observed a resident with chronic kidney disease, neurogenic bladder, paraplegia, and an indwelling catheter whose drainage bag was hanging on a wall hook with the catheter tubing lying across the top of the resident’s trashcan on two consecutive days. The resident’s care plan directed staff to check the tubing for kinks and keep the bag lower than the bladder, but did not address securing the tubing away from contaminated surfaces. Staff interviews revealed inconsistent understanding of whether it was acceptable to use a trashcan to keep catheter tubing off the floor, with some CNAs stating it was not acceptable and a CMA stating it was acceptable. A second deficiency was identified in the maintenance of housekeeping equipment. A housekeeper was observed using a housekeeping cart that had silver duct tape lining both sides of the top rolling door and the back access door. The tape was not fully affixed, leaving exposed adhesive that could harbor bacteria. The housekeeper reported the cart was new but had broken about a month earlier. The Environmental Services Director stated that housekeeping staff report repair needs to him and that equipment is replaced when damaged, and he acknowledged he was aware of the taped cart but did not realize the tape was being used as a repair method. A third deficiency involved failure to follow EBP requirements for a resident with chronic kidney disease, non-Alzheimer’s dementia, heart failure, diabetes, and a chronic right foot ulcer who required EBP due to wounds. An in-home nurse entered the resident’s room, removed the right foot dressings, and took pictures of the wound without wearing a gown, despite an active physician’s order for EBP and a posted EBP sign at the door specifying that gloves and a gown must be worn for wound care and other high-contact care activities. The nurse acknowledged receiving infection prevention education, noticed the resident was on EBP, and admitted he did not refer to the posted sign and refused to don a gown when prompted because he believed he was already finished in the room. During this interaction, he also held the resident’s drinking cup with the same gloved hands used for wound care.
Failure to Safely Administer Insulin and PRN Acetaminophen
Penalty
Summary
The deficiency involves failures in safe medication administration, particularly with insulin and acetaminophen. For one resident with chronic kidney disease and diabetes who required extensive assistance with ADLs and received insulin injections daily, an LPN prepared a fast-acting insulin FlexPen by attaching a needle and injecting the insulin into the resident’s abdomen without priming the pen to remove air. The LPN later acknowledged that the insulin pen should have been primed and that she had forgotten to do so. She also confirmed that the insulin pen was considered good for 30 days after opening but admitted there was no documented open date on the pen and that she had not noticed the blank date label before administering the dose. A second resident, who had chronic kidney disease, diabetes, heart failure, and morbid obesity and was cognitively intact but dependent for most ADLs, also received fast-acting insulin via FlexPen three times daily with meals. During observation, the same LPN correctly primed the insulin pen and administered the injection into the resident’s abdomen. However, after administration, the LPN stated she did not know when the insulin pen had been opened because it was not dated and admitted she had not checked the date-opened label before giving the insulin. Facility nursing staff, including an RN and another LPN, later stated that insulin pens should not be used if the date opened is not documented and that such insulin should be discarded and replaced. A third resident with diabetes, partial paralysis, and non-traumatic brain dysfunction, who required varying levels of assistance with mobility and ADLs, had a care plan for chronic pain directing staff to administer pain medication as ordered and monitor pain on a 0–10 scale. The resident’s physician order included acetaminophen 650 mg every six hours as needed for mild pain, and the order was on hold and did not include use for fever. When this resident was observed to be lethargic in a wheelchair at the dining table, staff obtained vital signs and reported a temperature of 100.4°F. The LPN instructed a CMA to administer acetaminophen, and the CMA attempted to give two acetaminophen tablets, but the resident refused by pulling her head back and saying no, at which point the CMA stopped. The LPN later acknowledged it was not acceptable to use a medication for a reason not included in the physician’s order and admitted she did not know the acetaminophen order did not include use for fever.
Inaccurate Documentation of Change in Condition and Notifications
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate health record for a resident who experienced a change in condition. The resident had moderately impaired cognition with a BIMS score of 12, and diagnoses including diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. The resident required varying levels of assistance with activities of daily living and had a care plan directing staff to involve her family in decisions and medical updates. On the day of the incident, an LPN attempted to wake the resident, who was lethargic and only responded after multiple taps to her arm. The resident’s temperature was obtained by a CMA and found to be 100.4°F, and the LPN instructed the CMA to administer Tylenol. The resident refused the Tylenol, pulling her head back and saying “no” twice. The LPN then directed a CNA to return the resident to her room. A nurse’s progress note entered at 12:05 PM documented that the resident was semi-responsive, responded to touch and voice only, had a temperature of 100.4°F, and refused Tylenol. The LPN left the unit for lunch at 12:19 PM and returned at 1:25 PM, stating she did not perform any work-related duties while at lunch. She later confirmed that the resident’s condition constituted a change in condition and acknowledged that a change-of-condition form should have been completed at that time. An eINTERACT Change in Condition Evaluation dated the same day documented family and provider notification at 1:00 PM, a time when the LPN reported she was at lunch. The ADON stated staff should not be backdating and should accurately record events to reflect the time they occurred. Facility policy on documentation required each resident’s medical record to be complete, accurate, and timely, containing an accurate representation of the resident’s actual experiences, which was not followed in this instance.
Failure to Provide Dignified Grooming and Shaving as Requested
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide dignified grooming and personal hygiene assistance as care-planned and requested for one resident. The resident’s quarterly MDS documented multiple diagnoses including coronary artery disease, diabetes mellitus, anxiety disorder, depression, a left hip fracture, and generalized muscle weakness, and indicated the resident required substantial or maximal assistance with personal hygiene. The resident’s care plan, last revised on 02/13/2026, specified that she preferred her hair to remain long and brushed daily and that she requested to be shaved daily, with this shaving preference initiated in the care plan on 02/22/2025. Despite this, direct observation on 02/10/2026 at 11:36 AM showed the resident with a long, substantial beard and matted, unwashed hair. During interviews, the resident reported she requested staff to help her shave whenever they offered a shower, preferred bed baths, and was told by staff they could not shave her because she was diabetic and that only a barber or nurse could shave her due to her diabetic status. She stated this lack of assistance increased her feelings of depression. Review of the Kardex for personal hygiene and bathing from 01/13/2026 to 02/11/2026 showed no documented refusals for showers, personal cares, or bathing, and indicated bathing was documented as occurring every day with extensive assistance provided on more than half of the opportunities. A facility barber reported hearing from other residents that staff refused to trim or cut facial hair and believed CNAs and shower aides could cut hair but that this was not regularly done due to staffing shortages. An RN confirmed the resident had been asking to have her facial hair removed for several days and was unsure if CNAs could shave a resident with diabetes. A CNA familiar with the resident confirmed the resident preferred to be clean shaven and that refusals would be documented in the EHR. The ADON confirmed shaving is provided for residents who request it and that staff are expected to provide this service, and facility policy on shaving required refusals to be reported to a nurse supervisor and documented in the medical record.
Failure to Timely Notify Physician and Family After Resident Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide timely physician and family notification when a resident experienced a change in condition. The resident had moderately impaired cognition, diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction, and required varying levels of assistance with activities of daily living. Her care plan directed staff to involve her family with decisions and medical updates. On the day of the incident, an LPN attempted to wake the resident while she was seated in her wheelchair at the dining room table; the resident was lethargic and required multiple taps or grabs of her arm to respond. The LPN moved the resident to a sunnier area and asked a CMA to obtain vital signs, which showed a temperature of 100.4°F. The LPN instructed the CMA to administer Tylenol, but the resident refused the medication twice, pulling her head back and saying no. The LPN then instructed a CNA to return the resident to her room. A nursing progress note documented at 12:05 PM that the resident was semi-responsive, responding only to touch and voice, and had a temperature of 100.4°F with refusal of Tylenol. Staff interviews, including RNs and LPNs, confirmed that a temperature of 100.4°F in a typically responsive resident who becomes lethargic and requires loud voice or touch to respond constitutes a change in condition that requires provider notification and documentation on an electronic change in condition form and in progress notes. The involved LPN acknowledged that the event was a change in condition and that the change-in-condition form should have been completed at that time, but she went to lunch at 12:19 PM without notifying another nurse and did not contact the resident’s brother and provider until after returning from lunch at 1:25 PM. An eINTERACT Change in Condition Evaluation later documented family and provider notification at 1:00 PM. The facility’s Notification of Changes policy required informing the resident, consulting with the physician, and/or notifying the family or legal representative when there is a significant change in the resident’s physical, mental, or psychosocial condition, such as deterioration in health or status, which did not occur in a timely manner in this case.
Failure to Assess and Intervene for Resident With Fever and Mental Status Change
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and intervene when a resident exhibited an elevated temperature and a change in mental status. The resident had moderately impaired cognition, diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction, and required varying levels of assistance with activities of daily living. The care plan noted memory problems but did not include directives for staff response to a mental status change. During observation, an LPN attempted to wake the resident, who was lethargic and required repeated tactile stimulation to respond. The LPN moved the resident to a brighter area and requested a CMA to obtain vital signs, which showed a temperature of 100.4°F. The LPN instructed the CMA to administer Tylenol, but the resident refused the medication twice. The LPN then directed a CNA to return the resident to her room. Despite recognizing that the resident was semi-responsive, with a temperature of 100.4°F and refusal of Tylenol, the LPN left the unit for lunch without contacting the provider or arranging for further assessment or monitoring by another nurse. A progress note documented the resident as semi-responsive, responding only to touch and voice, with a temperature of 100.4°F and refusal of Tylenol. Interviews with other nursing staff indicated that a temperature of 100.4°F and decreased responsiveness constituted a significant change in condition that warranted provider notification, frequent reassessment, and documentation. The LPN later acknowledged that the event was a change in condition and that she did not contact the provider until after returning from lunch. An eINTERACT Change in Condition Evaluation was completed but did not include any interventions, and the progress notes lacked follow-up assessments or interventions. The facility did not have a policy directly addressing assessment and interventions for such changes in condition.
Failure to Use Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe wheelchair transport by not using foot pedals for a resident who required assistance with mobility. Resident #8 had moderately impaired cognition, with a BIMS score of 12/15, and diagnoses including diabetes mellitus, partial paralysis, and non-traumatic brain dysfunction. The resident’s MDS indicated dependence or need for assistance with most mobility tasks, including transfers, bed mobility, and all other forms of mobility, and documented use of a wheelchair and walker. The resident’s care plan did not identify any non-compliance with wheelchair foot pedal use. On the observed date and time, an LPN (Staff A) attempted to wake the resident, who was seated in a wheelchair at the dining room table and was lethargic, requiring multiple taps or grabs of the left arm to elicit a response. Staff A then transported the resident in the wheelchair without foot pedals to a hallway area with more sunlight. Subsequent interviews with an RN (Staff D), another LPN (Staff E), and the ADON confirmed that staff understood residents should not be transported in wheelchairs without foot pedals and that feet should be on the pedals during transport unless the resident is self-propelling. Staff A acknowledged that foot pedals should have been applied during the transport. The facility did not have a policy that provided staff directives for transporting residents in wheelchairs.
Failure to Identify and Treat Unstageable Pressure Ulcer
Penalty
Summary
A resident with severe cognitive impairment, multiple comorbidities including anemia, diabetes, traumatic brain injury, malnutrition, and respiratory failure, was identified as being at very high risk for pressure ulcers. The resident was dependent on staff for bed mobility and transfers, and the care plan acknowledged risk factors such as impaired mobility, cognition, incontinence, and high-risk medications. However, the care plan failed to address an unstageable pressure ulcer on the left heel and lacked specific interventions for repositioning, turning, or floating the heels to prevent further breakdown or promote healing. Clinical documentation revealed repeated failures to assess, document, and treat the left heel pressure ulcer. Upon multiple admissions and readmissions, progress notes and skin assessments either omitted mention of the wound or lacked essential details such as wound measurements, characteristics, and treatment interventions. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect any wound care or new interventions for the left heel ulcer until several weeks after the wound was first identified. Even after wound care orders were received from the hospital, there was no documentation of consistent implementation of repositioning, turning, or heel floating as required by facility policy. Interviews with the DON and NP confirmed gaps in wound assessment, documentation, and intervention. The DON acknowledged omissions in skin assessments and was uncertain about the timing of heel protector use. Facility policies required regular turning, repositioning, and heel floating for residents at risk of or with pressure ulcers, but these interventions were not documented in the care plan or medical record. The lack of prompt assessment, documentation, and implementation of appropriate interventions contributed to the failure to provide care consistent with professional standards for pressure ulcer prevention and management.
Repeated Deficiencies in QAPI, Pressure Sores, Staffing, and Infection Control
Penalty
Summary
The facility failed to correct its own deficiencies and did not maintain an effective quality assurance program to ensure quality care for its residents and compliance with federal and state regulations. Over the past two and a half years, repeated deficiencies were cited in areas including pressure sores (F686), services to meet professional standards (F658), sufficient nursing staffing (F725), and infection control (F880). These deficiencies were identified during multiple surveys, including recertification, complaint, and incident surveys, with the same issues recurring across several survey cycles. The facility's QAPI plan outlined a systematic approach for identifying and addressing problems, but the repeated citations indicate that these processes were not effective in preventing recurrence of the same issues. Despite documentation of a QAPI plan and acknowledgment from the Administrator that various measures had been implemented, the facility continued to experience repeat deficiencies in critical areas affecting resident care. The Administrator confirmed that the facility had ongoing issues with pressure wounds, infection control, and staffing, and that these concerns persisted despite efforts to track and address them. The repeated nature of these deficiencies suggests that the facility's quality assurance activities were insufficient to achieve and sustain compliance with regulatory requirements.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with multiple complex medical needs, including a g-tube, suprapubic catheter, and tracheostomy. The resident was care planned for Enhanced Barrier Precautions (EBP) due to the presence of a catheter. Observations revealed that the Infection Control Preventionist provided oral care to the resident wearing only gloves and no gown, contrary to EBP requirements. Additionally, a registered nurse performed multiple dressing changes on the resident's wounds, catheter, g-tube, and tracheostomy without changing gloves or performing hand hygiene between sites, as required by facility policy. Further observation showed the same nurse administering medication via the resident's g-tube without wearing gloves or a gown. Review of facility policies confirmed that EBP requires gown and glove use during high-contact care activities, including device care and wound care, and that hand hygiene must be performed after handling contaminated objects and between dressing changes. The Infection Control Preventionist acknowledged these lapses in infection control practices during an interview.
Failure to Follow Infection Control Protocol During Suprapubic Catheter Care
Penalty
Summary
A deficiency was identified when a registered nurse failed to follow proper infection control procedures while providing wound and suprapubic catheter care to a resident with multiple complex medical conditions, including muscular dystrophy, respiratory failure, dysphagia, malnutrition, and a suprapubic catheter. During observation, the nurse performed two wound treatments and then proceeded to change the suprapubic catheter dressing without changing gloves between procedures. The nurse also cleansed the catheter insertion site by repeatedly wiping the same area with the same part of the gauze pad, contrary to facility policy, which requires using a new cotton ball or applicator for each outward stroke from the stoma. The resident's clinical record revealed an incident where the resident was found with blood in the urine and large sediment in the catheter tubing, resulting in a transfer to the emergency room. Subsequent laboratory testing confirmed a urinary tract infection with a high bacterial count. Facility policy and infection control expectations, as confirmed by the Infection Control Preventionist, require hand hygiene, glove changes, and proper technique when cleaning the suprapubic catheter site, which were not followed during the observed care.
Failure to Flush G-Tube Before and After Medication Administration
Penalty
Summary
A deficiency occurred when a registered nurse failed to follow facility policy regarding the administration of medication through a gastrostomy tube (g-tube) for a resident with multiple complex medical conditions, including muscular dystrophy, respiratory failure, dysphagia, malnutrition, a suprapubic catheter, and a tracheostomy. The nurse administered a syringe containing three medications mixed with an unspecified amount of water directly into the resident's g-tube without flushing the tube with water before or after the medication administration, as required by facility policy. Facility policy, revised on 9/16/25, specifies that the enteral tube should be flushed with at least 15 ml of water prior to and after administering medications. The nurse stated there was no set amount for the water flush and indicated it did not matter, which was inconsistent with both the policy and the Director of Nursing's expectations. The Director of Nursing confirmed that, in the absence of a specific physician order, the protocol is to flush with 30 or 60 ml of water before and after medication administration.
Delayed Call Light Response and Inaccessible Call Lights
Penalty
Summary
The facility failed to provide timely responses to resident call lights and did not ensure call lights were within reach for certain residents. Resident council minutes documented ongoing concerns about delayed call light responses, with residents reporting that response times often exceeded the facility's standard of 15 minutes, particularly during the night shift when waits could reach up to 40 minutes. Interviews with cognitively intact residents confirmed these delays, and the Director of Nursing acknowledged the expectation for call lights to be answered within 15 minutes. Additionally, observations revealed that two residents with significant physical and cognitive impairments did not have their call lights within reach for extended periods. One resident, dependent on staff for transfers and toileting due to hemiplegia and dementia, was observed unable to access the call light, which was placed approximately five feet away. Another resident with muscular dystrophy, respiratory failure, and a tracheostomy was observed in bed for over two hours with the call light on the floor, out of reach, despite multiple staff entering the room during that time. Facility policy requires call lights to be accessible to all residents, but this was not consistently followed.
Failure to Notify Family of Significant Weight Loss and Dietary Changes
Penalty
Summary
The facility failed to notify the family or emergency contact of a resident who experienced significant weight loss and changes in nutritional management. Clinical record review and staff interviews revealed that a resident with severe cognitive impairment, multiple diagnoses including anemia, diabetes mellitus, traumatic brain injury, malnutrition, and respiratory failure, experienced notable weight loss over several months. The resident was dependent on staff for eating and received the majority of their nutrition via a feeding tube. Progress notes documented an 8.8-pound (5%) weight loss in one week and an 11.9-pound (7.3%) weight loss in one month, with a total loss of 21.4 pounds (12.4%) over three months. The dietician made recommendations to adjust tube feeding to address the weight loss. Despite these significant changes, there was no documentation in the clinical record that the resident's family or emergency contact was notified about the weight loss or the dietary recommendations. The DON confirmed that she could not locate any documentation of family notification and acknowledged that, although she had multiple conversations with the family, these were not documented. Facility policy required prompt notification of the resident's representative in the event of significant changes in the resident's condition, but this was not followed in this case.
Failure to Obtain Weekly Weights for Residents with Feeding Tubes
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice by not obtaining weekly weights as ordered by physicians for three residents with feeding tubes. Clinical record reviews, staff interviews, and policy review revealed that physician orders for weekly weight monitoring were not followed for these residents, despite their high risk for nutritional issues due to conditions such as malnutrition, anemia, diabetes, traumatic brain injury, cerebrovascular accident, and respiratory failure. Care plans for these residents specifically identified the need for close nutritional monitoring, including regular weights, due to their dependence on tube feeding and other complex medical needs. For one resident, only a single weight was documented in the month of May, despite a physician order for daily weights for three days followed by weekly weights. Progress notes indicated significant weight fluctuations and insufficient documentation of weights, with the dietician noting the lack of weekly weights and recommending changes to tube feeding due to observed weight loss. Another resident had multiple missed weekly weights over several months, as shown in the weight summary and treatment administration records. Staff interviews confirmed ongoing issues with obtaining accurate and timely weights, with equipment problems and staff performance cited as contributing factors. A third resident with multiple complex medical diagnoses, including muscular dystrophy, respiratory failure, and malnutrition, also had physician orders for daily and weekly weights that were not consistently followed. Medication administration records and weight logs showed only sporadic documentation of weights over a two-month period. Facility policy required implementation of a weight monitoring schedule and timely recording of weights, but this was not adhered to for these residents, resulting in a failure to meet professional standards of quality for monitoring nutritional status.
Failure to Maintain Safe and Homelike Environment Due to Unresolved Maintenance Issues
Penalty
Summary
Surveyors observed multiple deficiencies related to the facility's failure to provide a safe, clean, comfortable, and homelike environment for its residents. Several room doors could not be properly closed, even after repeated attempts by staff and surveyors. In one room, a board intended for the window sill was found lying on the floor by the resident's bed for over a month, and the platform for the window sill had hard, dried glue and a rough surface. Additionally, the bathroom call light in one room was not functioning, and a 4-plex electrical outlet was being used to power a dorm-sized refrigerator, a charger for a motorized wheelchair, and a charger for electronic devices, with reports of the outlet sparking when used. Review of facility work orders revealed that there were no open or active work orders for the affected rooms during the survey period, despite ongoing issues. Interviews with residents confirmed that maintenance requests had been made but not addressed in a timely manner. Staff interviews indicated that work orders were entered into the facility's TELS system, but repairs were not always completed promptly. The maintenance director confirmed that work orders were prioritized by urgency, but some issues, such as the broken windowsill and malfunctioning electrical outlet, persisted for extended periods before being addressed.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Delayed Call Light Response Across Multiple Units
Penalty
Summary
The facility failed to provide timely responses to resident call lights on three of four units, as evidenced by multiple resident and family interviews, as well as documentation in Resident Council Minutes. Residents consistently reported waiting 20 to 50 minutes for staff to respond to call lights, with some instances where staff turned off the call light and did not return for an extended period. Resident Council Minutes from April, May, and June 2025 documented ongoing concerns about delayed call light responses, and several cognitively intact residents confirmed these delays during interviews. A family member also reported frequent delays of 30 minutes or more for call light responses. The Director of Nursing acknowledged awareness of the issue and stated that the facility's standard is to answer call lights within 15 minutes. Despite this expectation, the reported experiences indicate that the facility did not consistently meet the needs of residents for timely assistance, as required.
Failure to Follow Infection Control Practices for Residents with Medical Devices
Penalty
Summary
Staff failed to follow infection control practices for a resident with a feeding tube and another with a catheter. For the resident with a feeding tube, a registered nurse donned gloves and gown for Enhanced Barrier Precautions (EBP) but did not perform hand hygiene or remove gloves between tasks such as obtaining vital signs, administering insulin, handling medication packaging, and documenting care. Equipment used for blood sugar, blood pressure, and pulse oximetry was placed back into the medication cart without being sanitized. The nurse continued to access the medication cart and administer medications via gastrostomy tube without changing gloves or performing hand hygiene, only removing gloves and gown at the end of the process. Additionally, certified nursing assistants providing hygiene and transfer for the same resident donned gowns and gloves but failed to perform hand hygiene between glove changes and did not consistently don new gowns as required by EBP protocols. For the resident with an indwelling catheter, observations on three separate occasions revealed that the catheter bag was lying on the floor with the drain port touching the floor. The Director of Nursing confirmed during an interview that the catheter bag should not be on the floor. These findings were based on direct observation, staff interviews, and policy review, and indicate lapses in adherence to established infection prevention and control procedures for residents with medical devices.
Failure to Notify Provider of Change in Condition for Resident with Hyperglycemia and Tachycardia
Penalty
Summary
The facility failed to promptly notify a medical provider of a significant change in condition for a resident with multiple complex medical diagnoses, including diabetes, stroke, aphasia, and seizure disorders. The resident, who was nonverbal and received the majority of her nutrition via tube feeding, exhibited persistently elevated blood glucose levels over several days, with readings as high as 437, 413, and 397. Additionally, the resident's heart rate was consistently elevated, reaching up to 126 beats per minute, and her blood pressure was trending below baseline. Despite these abnormal findings, there was no documentation that a medical provider was notified of the resident's high blood sugars or tachycardia prior to her acute deterioration. Nursing documentation was notably lacking, with no progress notes entered for a period of nearly two weeks, and the only note during that time referencing a physician note with no new orders. Staff interviews revealed that while some staff recognized the abnormal blood sugar levels and vital signs, there was inconsistency in when to notify a provider, and no action was taken until the resident's condition became critical. When the resident's blood glucose became unreadable by the glucometer, a provider was contacted but did not give orders for insulin, only for tube feeding to be stopped and labs to be drawn. The resident was ultimately sent to the emergency department after further decline, where she was diagnosed with diabetic ketoacidosis, sepsis, and pneumonia. The lack of timely provider notification and absence of additional insulin administration outside of scheduled doses contributed to a delay in appropriate medical intervention. The facility's documentation and communication practices did not reflect prompt recognition or escalation of the resident's deteriorating condition, despite clear evidence of significant changes in vital signs and blood glucose levels.
Failure to Provide Adequate Supervision and Follow Care Plan Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and follow the care plan for a resident with severe cognitive impairment, resulting in a fall. The resident had a history of dementia, anxiety disorder, a prior humerus fracture, and required substantial to maximal assistance with transfers and toileting according to the most recent MDS and care plan. Despite these documented needs, the resident was allowed to ambulate independently from the bathroom to her chair, during which she fell and sustained a significant skin tear and bruising, and later complained of pain in her right big toe and left arm. Staff interviews and documentation revealed inconsistencies in the assignment and supervision of care for the resident on the day of the fall. The care plan directed staff to provide assistance with transfers and all toileting tasks, but staff accounts indicated that the resident was often left to use the bathroom independently for privacy, with staff only nearby rather than providing direct assistance. There was also confusion among staff regarding the resident's level of independence, with some believing she was care planned to be independent for transfers and toileting, while others stated she required assistance. The care plan had not been updated to reflect changes in the resident's condition, and staff were not consistently following the documented interventions. Further, the facility's policies required ongoing assessment and adjustment of interventions for residents at risk of falls, as well as accurate documentation and communication among staff. However, the care plan was outdated, and staff were unclear about the resident's needs and the required level of supervision. The lack of direct supervision and failure to adhere to the care plan led to the resident's fall and injury, demonstrating a breakdown in communication, care planning, and implementation of fall prevention strategies.
Failure to Perform Post-Dialysis and Post-Fall Assessments and Document Missed Medications
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for two residents. For one resident with multiple complex diagnoses, including end stage renal disease, diabetes, and heart failure, staff did not perform a post-dialysis assessment or assess for side effects after missed medication doses. The resident returned from a scheduled hemodialysis appointment, but there was no documentation of post-dialysis weight, vital signs, or assessment of the dialysis access site. Additionally, several scheduled medications were not administered because the resident was away from the facility, but there was no evidence of physician notification or follow-up assessment for potential side effects related to the missed doses. Later that day, the resident exhibited abnormal vital signs, lethargy, and hypothermia, and was transferred to the hospital. The review of facility records and staff interviews revealed that the facility's care plan and medication administration records lacked specific instructions and documentation regarding fluid restriction amounts and post-dialysis assessments. Staff confirmed that post-dialysis assessments were not consistently documented, and that there was no process in place to ensure communication with the dialysis center if documentation was missing. The facility's own policies required coordination with the dialysis center, monitoring and documentation of the access site, and timely communication regarding medication administration, but these were not followed in this case. For another resident at risk for falls, the facility failed to document a post-fall assessment within 24 hours after a witnessed fall. Although staff reported assessing the resident's vitals, pain, and orientation after the fall, this information was not entered into the medical record until the following day as a late entry. The facility's policies required timely documentation of incidents and assessments in the medical record, but this was not completed as required. The lack of timely documentation meant that pertinent information about the resident's condition and the circumstances of the fall were not available in the medical record as expected.
Failure to Ensure Safe Transfers and Equipment Use for Residents Requiring Mechanical Assistance
Penalty
Summary
The facility failed to provide adequate supervision and appropriate assistance devices to prevent accidents for two residents requiring mechanical equipment transfers. One resident, with no cognitive impairment and dependent on staff for transfers and activities of daily living, was observed being transferred by two staff members using a gait belt. However, one staff member lifted the resident by the waist of his pants and under his shoulder, rather than solely using the gait belt as required. The resident's care plan specified the use of a platform walker and one-person assistance for transfers, but this was not followed during the observed transfer. Another resident, with intact cognitive function and diagnoses including hemiplegia, dementia, cancer, anemia, and orthostatic hypotension, was totally dependent on staff for transfers. The resident sustained an injury during a transfer when a CNA used a sit-to-stand mechanical lift instead of the required full body mechanical lift, and only one staff member assisted instead of two as specified in the care plan. The resident, who was on blood thinners, developed a bruise and discomfort as a result of the improper transfer. Documentation confirmed that the CNA did not follow the plan of care, and the incident was reported to the family. Additionally, an observation of the sit-to-stand mechanical lift used in the facility revealed severely damaged foam padding on the handles, exposing sharp metal edges where hands are placed during use. This compromised equipment was confirmed by both the Administrator and the DON, who removed it from service. Facility policy clearly states that damaged or improperly functioning lift equipment should not be used, but this was not adhered to at the time of the incident.
Delayed Call Light Response and Inadequate Staffing
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to resident call lights and assistance with care needs for multiple residents. Observations and interviews revealed that several residents experienced significant delays in staff response, with call lights often going unanswered for 15 minutes or longer. One resident, who was on strict bedrest due to a lumbar fracture, reported frequent delays of up to 40 minutes and sometimes turned off the call light herself when it was not answered. Another resident, dependent on staff for mobility and personal care, stated that it could take up to an hour for staff to respond to his call light, particularly during peak times, and staff attributed the delays to being short-staffed. Additional observations documented a resident who was incontinent and dependent on staff for toileting was left in visibly wet clothing for at least 23 minutes before being assisted, despite staff being made aware of his condition. Another resident with an indwelling urinary catheter and at risk for skin breakdown activated his call light and waited 16 minutes before a nursing assistant responded, who then informed the resident that a nurse would be notified and assistance would be provided later. These delays were observed despite the facility's policy and staff expectations that call lights should be answered within 15 minutes. The facility's own policies required all staff to respond promptly to call lights and to ensure that residents' needs were met in a timely manner. However, both staff and residents reported and demonstrated through observation that call light response times frequently exceeded the facility's expectations, particularly during busy periods or when staffing was not optimal. The documented delays in responding to residents' needs resulted in residents remaining in uncomfortable or potentially unsafe situations for extended periods.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice in resident rooms for two of three residents reviewed. One resident reported seeing a mouse in her room for the past four months, with traps being set off but not catching the mouse, and sticky traps disappearing. Observations confirmed the presence of a mouse trap and possible mouse droppings in the resident's room. Another resident, living across the hall, reported a mouse living in his closet, which he stated to the Director of Maintenance. Staff interviews revealed that complaints about mice had been made to maintenance, but the pest control company had not received any reports of mice in the last six months and had not conducted any inspections or treatments for mice during that period. Further observations identified structural issues at an exit door near the affected rooms, including visible gaps and missing weather guard, which could allow pests to enter. Staff interviews indicated that complaints about mice had been ongoing, with the DON acknowledging reports for four months and entering them into the facility's reporting system. However, the Director of Maintenance denied receiving reports about mice and stated that only moths had been reported previously. The facility's policy required maintaining a report system for pest issues between scheduled pest control visits, but this was not effectively implemented, leading to a failure to address the pest problem.
Failure to Maintain Nutritional Status
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, resulting in a significant weight loss of 10.4% over approximately three months. The resident, who had moderate cognitive impairment and depression, was not on a physician-prescribed weight-loss regimen. Despite a care plan intervention to provide Glucerna with each meal, no additional interventions were documented to address the weight loss. Observations revealed that the resident's meals were not individualized or separated from other residents' trays, and the resident often slept through meal times, leaving meals untouched. The resident expressed a preference for Bosnian food, but no specific cultural dietary interventions were implemented. The facility's registered dietitian and director of nursing acknowledged the resident's significant weight loss and lack of interventions beyond Glucerna. The facility's policies on nutritional management and unplanned weight loss were not adequately followed, as evidenced by the lack of individualized interventions and monitoring of the resident's nutritional status. Despite awareness of the resident's weight loss, the facility did not implement additional supplements or fortified foods until much later, and there was no documentation of dietary notes with additional supplements until after the deficiency was identified.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement proper infection control practices during resident-staff interactions, as observed in multiple instances. In one case, two Certified Nurse Aides (CNAs) improperly positioned a resident's indwelling catheter bag above the bladder, contrary to the care plan and training, which directed that the bag should be below the bladder to prevent backflow of urine. Both CNAs acknowledged the mistake, and the Director of Nursing (DON) confirmed the correct procedure was not followed. In another instance, a Certified Medicine Aide (CMA) entered a resident's room, who was on contact isolation and Enhanced Barrier Precautions (EBP), without donning Personal Protective Equipment (PPE) or performing hand hygiene. The CMA handled items in the room and returned without following proper isolation protocols. The DON stated that PPE should have been applied before entering the room, as per the facility's policy on transmission-based precautions. Additional observations revealed multiple staff members failing to perform hand hygiene before and after various tasks, such as medication administration and catheter care. Staff members were seen not changing gloves between tasks or performing hand hygiene, which is against the facility's policies on hand hygiene and PPE use. The Executive Director acknowledged these lapses and stated that staff should adhere to the established protocols for hand hygiene and PPE use.
Failure to Secure Resident Information
Penalty
Summary
The facility failed to secure Electronic Health Record information for 16 residents, as observed during a survey. On the evening of September 17, 2024, a report sheet containing information for 21 residents was found laying face up on a medication cart in the northeast hall. This was contrary to the facility's policy, which requires such information to be kept under a binder to ensure confidentiality. The Director of Nursing acknowledged that the resident information should not have been left exposed on top of the cart. The facility's policy on Confidentiality of Information and Personal Privacy, revised in October 2017, mandates the safeguarding of personal privacy and confidentiality of all resident personal and medical records.
Staff Argument and Privacy Breach in LTC Facility
Penalty
Summary
The facility failed to uphold the dignity of its residents when two staff members, a Dietary Attendant and Culinary Support, engaged in a loud argument in the presence of nine residents in the dining room. The incident occurred when the Dietary Attendant accused the Culinary Support of not helping and expressed frustration by yelling and throwing napkins. This behavior was witnessed by the residents and was audible from outside the dining room, indicating a breach of the facility's policy on treating residents with dignity and respect. Additionally, the facility did not adequately protect the confidentiality of resident information. A CNA charting monitor was left open and unattended in the hallway, displaying information for several residents. A Licensed Practical Nurse walked by without closing the screen, and another CNA accessed the monitor shortly after. The Executive Director confirmed that the monitors should be locked when not in use to protect resident privacy, as per the facility's policy on confidentiality and personal privacy.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer for a resident who was admitted with a Stage IV pressure ulcer and had comorbidities making her susceptible to further skin integrity issues. The resident required assistance for repositioning and was dependent on staff for turning and transfers. Despite this, the facility did not provide the recommended every 2-hour repositioning, and there were lapses in the documentation of these activities. The resident's care plan did not include a specific turning/repositioning schedule, and the care plan had not been updated since 2023. The resident developed a second Stage IV pressure ulcer, which required medical intervention and hospitalization. The facility's records showed inconsistencies in the documentation of wound care treatments, with gaps in treatment administration for the sacral wound. The resident's skin condition worsened, leading to the development of an unstageable pressure ulcer, which was later identified as a Stage IV pressure injury. The facility's failure to consistently implement and document wound care treatments contributed to the deterioration of the resident's skin condition. Interviews with staff revealed that the resident occasionally refused repositioning, but this was not consistently documented. The facility's policy on turning and repositioning was not effectively implemented, and there was a lack of communication and follow-up on wound care orders. The resident expressed concerns about the timeliness of repositioning and the need for staff assistance, indicating that the facility did not adequately address her needs for pressure ulcer prevention.
Failure to Prevent Pressure Ulcers in At-Risk Residents
Penalty
Summary
The facility failed to provide adequate care and interventions to prevent the development of pressure ulcers for two residents identified as at risk. Resident #1, who was admitted with diagnoses including septicemia and dementia, was initially assessed as having intact skin but later developed unstageable deep tissue injuries on both heels and a skin tear on the right buttock. Despite being identified as high risk for pressure ulcers, the resident's care plan was not effectively implemented, as evidenced by the lack of timely application of heel protector boots and an air mattress, which were only provided after the wounds were discovered. The resident's condition deteriorated, leading to hospitalization for septic shock and respiratory failure. Resident #2, with a history of stroke, hemiplegia, diabetes, and malnutrition, was also at risk for pressure ulcers. Initially, the resident had intact skin, but over time developed a Stage IV pressure ulcer on the sacrum. The care plan included the use of pressure-reducing devices and frequent repositioning, but these measures were insufficient or not consistently applied, as indicated by the progression of the wound from a Stage III to a Stage IV ulcer. The resident's condition worsened, resulting in a transfer to the hospital, where the resident later passed away. Interviews with staff revealed systemic issues, including inadequate staffing levels, which contributed to delays in repositioning and changing residents, leading to the development of pressure ulcers. Staff reported challenges in maintaining consistent care due to high resident acuity and insufficient personnel, which hindered their ability to perform necessary interventions timely. The facility's failure to implement effective pressure ulcer prevention strategies and address staffing shortages directly contributed to the deficiencies observed.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of residents, as evidenced by observations, interviews, and record reviews. On multiple occasions, call lights were left unanswered for extended periods, with some residents waiting up to two hours for assistance. This lack of timely response was attributed to inadequate staffing levels, particularly on the night shift, where only three CNAs were available for 61 residents. Interviews with residents and family members revealed dissatisfaction with the care provided, citing delays in assistance, inadequate feeding support, and concerns about staff being too busy or distracted. The facility's staffing issues were further highlighted by the involvement of administrative staff in direct care tasks, such as passing meal trays and answering call lights, particularly when state surveyors were present. Staff interviews confirmed that the facility often operated with minimal staffing, leading to unmet care needs, such as delayed repositioning, increased skin issues, and weight loss among residents. The facility's reliance on a scheduling software, On-Shift, was noted, but discrepancies between scheduled and actual staffing levels were reported, with staff frequently calling in and shifts going unfilled. The facility's assessment and staffing plan indicated a need for more staff than were actually present, with a significant number of residents requiring assistance from two staff members for transfers. Despite the facility's policy for timely call light response, the actual practice fell short, with residents experiencing prolonged waits for assistance. The Director of Nursing and other staff expressed concerns about the facility's ability to meet residents' needs due to budget constraints and management's reluctance to approve overtime or use agency staff.
Facility Lacks Effective QA Program Leading to Repeated Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance (QA) program, which is essential for providing quality care to residents and ensuring compliance with Federal regulations and State rules. The facility, with a census of 116 residents, has a history of repeated deficiencies as identified in its annual surveys and complaint investigations. Specifically, deficiencies F725 and F686 were repeatedly cited during surveys conducted on various dates, indicating persistent issues that were not adequately addressed. The facility's QA program, which was supposed to be a systematic approach for performance improvement, failed to prevent or decrease the likelihood of problems. Despite implementing a Quality Assurance and Performance Improvement (QAPI) change process in October 2022, the facility continued to experience systemic problems. The new Administrator, who started in March 2024, acknowledged the ongoing issues and the need for improvement, particularly in areas affecting the facility's 5-Star Rating Scale, such as pressure ulcers. However, the report does not detail any specific actions taken by the previous administration to address these deficiencies, highlighting a lack of continuity and effectiveness in the facility's QA efforts.
Failure to Ensure Resident Dignity
Penalty
Summary
The facility failed to ensure the dignity of a resident who was observed sitting in the commons area with her adult brief completely exposed. The resident, who has severely impaired cognitive skills, is always incontinent of bowel and bladder, and requires total assistance with personal hygiene care, was seen without pants and with her adult brief exposed on two separate occasions. Staff interviews revealed that the resident only had dresses to wear, which were provided by her family, and that staff would usually cover her with a blanket or sheet, which she would sometimes remove. Despite this, the resident was left exposed in the commons area for extended periods. The Director of Nursing was informed of the situation but could not comment as she had not witnessed it herself. The facility's dignity policy, which emphasizes treating residents with dignity and respect at all times, was not adhered to in this instance. The policy aims to promote residents' well-being, satisfaction with life, and self-worth, but the observed actions and inactions of the staff failed to uphold these standards for the resident in question.
Failure to Initiate Physician's Orders and Administer Medications
Penalty
Summary
The facility failed to initiate physician's orders for two residents, leading to deficiencies in their care. Resident #1, who had a BIMS score of 12 indicating no cognitive impairment, was admitted with a Stage 2 pressure ulcer. Despite weekly recommendations from the wound physician to administer vitamin C 500 mg twice daily, the facility did not initiate this order from February to April 2024. The Director of Nursing acknowledged that the order should have been started, and the responsibility for initiating these recommendations was assigned to the wound nurse, Staff C Unit Manager. Resident #2, who had a BIMS score of 3 indicating severe cognitive impairment, was admitted from a hospital with multiple diagnoses including metabolic encephalopathy and seizures. The facility failed to administer his prescribed medications upon admission due to unavailability at the pharmacy. Despite attempts to obtain the medications in pill form, the resident experienced seizure episodes and was eventually sent to the emergency room. The Director of Nursing confirmed that the medications were not administered on the day of admission because they were delivered late, and staff did not seek an order to administer them late. The facility's policies on medication orders and admission orders were reviewed, revealing that the procedures for receiving and recording medication orders were not followed. The facility's failure to administer prescribed medications and initiate physician's orders for wound care led to significant deficiencies in the care provided to these residents.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to ensure that a resident received appropriate assistance with their activities of daily living (ADLs). The resident, who has severely impaired cognitive skills, is non-verbal, and requires total assistance for personal hygiene and dressing, was observed multiple times over two days in a state of neglect. The resident was seen lying in bed for extended periods, wearing a hospital gown, and later sitting in a Broda chair in the commons area with no pants on, exposing her adult brief. Her hair was noted to be unkempt, oily, and balled up, indicating a lack of proper grooming and care as per the facility's policies on brushing and combing hair and maintaining resident dignity. Interviews with staff revealed inconsistencies in the care provided to the resident. Staff A, a CNA, admitted that the resident is usually checked every two hours and changed when needed but acknowledged that the resident had been left in bed until after lunch due to staffing issues. Staff B, another CNA, confirmed that the resident is typically up in her chair by 10:00 AM but also noted that the resident had been left in bed for longer periods recently. Both CNAs acknowledged the resident's unkempt hair and the difficulty in grooming it, with Staff B mentioning that the resident makes noises when they try to comb her hair, leading them to stop. The Director of Nursing (DON) confirmed that the resident's routine involves getting up once a day and sitting in the lobby area. The DON also acknowledged the issue with the resident's hair, attributing the knots to saliva pooling on the back of her head. Despite the facility's policies requiring daily grooming and maintaining resident dignity, the resident was observed in a state that did not meet these standards, indicating a failure in providing the necessary care and assistance with ADLs.
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A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Two residents who were cognitively impaired and dependent on staff for personal care did not receive bathing assistance at least twice weekly as required by facility policy. Facility records showed multiple instances where bathing was documented as refused or not applicable, resulting in gaps of 6, 7, and 11 days between baths. The care plan for one resident specified total dependence on staff for bathing, and the facility’s policy required showers to be offered at least twice weekly and on the next available day if missed. The DON reported that staff are expected to continue offering showers and try different approaches after refusals, but the documented bathing intervals did not reflect this practice.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
A resident with COPD, pneumonia, and respiratory failure was transferred to the hospital for acute respiratory distress and later deemed medically ready for discharge, but the facility delayed readmission by three days due to staffing and admission timing practices. Facility staff, including an RN, MDS coordinator, ADON, DON, and Administrator, reported that they avoided weekend and evening admissions, required two nurses for admissions, and were concerned about entering medication orders into the EMR in time for pharmacy delivery when only one nurse was on duty. They did not notify the provider about the planned discharge back, did not arrange alternative pharmacy or transport options, and cited shared transport and lack of additional nurses as reasons the readmission was not feasible, despite the facility’s stated commitment to 24-hour nursing care and medication management.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
Failure to Provide Twice-Weekly Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance at least twice weekly, as required by its own policy, for two residents who were dependent on staff for bathing. For one resident with anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive impairment, the MDS documented total dependence on staff for bathing. Facility documentation showed that bathing was recorded as refused on one date, with actual baths provided on dates that resulted in a 6‑day interval without a bath on two separate occasions. The resident’s care plan indicated the resident was totally dependent on staff to provide a bath as necessary. For another resident with diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, facility records showed multiple dates where bathing was documented as refused or as not applicable. Review of the Follow Up Question Report demonstrated several extended gaps between baths: 6 days on two occasions, 7 days on one occasion, and 11 days on another, despite the facility policy requiring showers to be offered at least twice weekly and, if missed, to be offered on the next available day. In an interview, the DON stated that when a resident refuses a shower, staff are expected to continue to offer, try multiple times, try a different person, and continue to try the next day until the resident bathes, which was not reflected in the documented bathing intervals for these two residents.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Delayed Hospital Readmission Due to Insufficient Nursing Staff and Admission Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and related processes to support the timely readmission of a hospitalized resident, resulting in a three-day delay in the resident’s return. The resident had moderately impaired cognition, with a BIMS score of 12/15, and medical diagnoses including COPD with acute exacerbation, pneumonia, and respiratory failure. The resident was transferred to the hospital after staff observed labored respirations, use of accessory muscles, diaphoresis, an oxygen saturation of 85% on room air, and wheezing, with improvement after oxygen was applied but continued labored breathing. Hospital records show the resident was admitted and later determined medically stable and ready for discharge, with documentation that the patient was planned for discharge but was not accepted back to the facility due to timing issues and would remain in the hospital over the weekend. Hospital progress notes documented that the resident was medically ready for discharge and that discharge was planned but not completed because the facility would not accept the resident later in the day. A hospital case management/social work note indicated confirmation that the facility could take the patient on the day the resident ultimately returned. The facility’s EHR showed the resident’s billing status changed to STOP BILLING on the date of hospital transfer and back to active several days later, corresponding to the delayed readmission. The resident reported spending three days in the hospital before being able to return to the facility. Multiple staff interviews described facility practices that contributed to the delay in readmission. An RN stated the facility tried not to do admissions on weekends and did not want admissions after 2 p.m. so nurses could complete admission tasks and enter medications into the computer in time for pharmacy delivery. The MDS Coordinator stated the facility liked residents readmitted before 2 p.m. to obtain medications, that the hospital had informed them the resident would not return until early evening, and that the facility needed two nurses in the building for an admission; the coordinator also stated the facility did not do admissions on weekends and was unsure about using another pharmacy or family to obtain medications. The ADON and DON both stated that with only one nurse on duty, a readmission later in the day was not feasible due to the time needed for admission assessments and medication entry, and they cited concerns about not having medications on time and the workload of one nurse caring for existing residents and completing a readmission. The DON further stated the facility did not accept evening or Saturday admissions for safety reasons, did not notify the provider about the planned discharge back to the facility, and did not explore hospital-supplied medications or alternative transport options, while acknowledging the presence of on-call nurses. The Administrator confirmed that with only one nurse, a readmission was considered not doable. The facility lacked written transportation or readmission policies and relied on general CMS and Resident Rights guidance, while its Resident Handbook stated residents receive individualized 24-hour nursing care and medication management.
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