Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chapters Living Of Council Bluffs during CMS and state inspections, most recent first.
The deficiency involves multiple failures in pressure ulcer prevention, assessment, and treatment for several residents. A resident admitted without ulcers developed an in-house Stage 2 sacral pressure injury that was not consistently measured or fully assessed for several weeks, despite documented infection and worsening appearance. Staff did not reliably notify the NP or MD of deterioration, did not change treatment orders in a timely manner, and did not update the care plan with new interventions, while the resident reported not being repositioned every 2 hours and sometimes remaining in a saturated brief overnight. Another resident with incontinence-associated dermatitis and documented skin risk had wound assessments with missing or inconsistent measurements, photos showing apparent Stage 2 sacral/coccygeal ulcers that were not documented as such, and a care plan that did not reflect the specific skin issues or interventions identified on the MDS. Staff interviews and the DON’s statements confirmed gaps in CNA reporting, nurse assessment, physician notification, and overall wound care practices.
Surveyors found that the facility failed to consistently involve residents and their representatives in interdisciplinary care plan conferences and did not keep care plans current with residents’ changing clinical conditions. Several residents and families reported they had not been invited to care conferences since a change in ownership, and the social services director acknowledged many conferences were not completed or documented. Care plans for multiple residents were not revised to reflect new transfer requirements (e.g., need for a full-body mechanical lift), new or discontinued indwelling catheters, new diagnoses such as influenza requiring EBP and droplet precautions, and the development or progression of pressure injuries, including MASD, DTI, Stage 2 ulcers, and a surgically debrided Stage 4 sacral ulcer with a wound vac. Staff interviews showed that the MDS coordinator was largely responsible for care plan updates, floor nurses generally did not revise care plans, and IDT participation and documentation of care conferences were inconsistent, resulting in outdated or incomplete care plans that did not match current orders or resident needs.
Inaccurate PBJ Staffing Data Submission: The facility failed to submit accurate PBJ staffing data for Q4 2025 after the report triggered for non-submission and a one-star staffing rating. Staff interviews and schedule reviews showed inconsistent RN and CNA coverage across shifts, including times with no RN coverage on weekends and occasions when the facility was short staffed due to call outs. The Administrator acknowledged the PBJ data was being pulled incorrectly, with staff assigned to the wrong care areas, and stated the facility assessment staffing figures were approximate rather than minimums.
Repeated QAPI and PIP Deficiencies: The facility had multiple repeat deficiencies across several surveys, including infection prevention and control, quality of care, staffing, resident rights, assessments, and sanitary food handling. Review of records found no QAPI policy describing how adverse events or problem-prone concerns were identified, tracked, investigated, or analyzed, and no current PIPs were in place. The Administrator stated the QAPI committee had not been very good at developing PIPs and that the facility had been building its own policies as it went.
Missing QAPI Policy and PIPs: Clinical record review found no QAPI policy describing how the facility would identify, report, track, investigate, and analyze adverse events or problem-prone concerns, no process for using resident representative feedback, and no method to monitor whether performance improvement activities were effective and sustained. The Administrator stated the facility did not currently have a QAPI policy and had not developed any PIPs, noting the facility had been building its own policies as it went.
QAA committee meetings did not consistently include the required members, and the facility had no QAPI policy in place. Attendance records showed meetings without the IP, Medical Director, DON, or ADON present, and the Administrator acknowledged that some quarterly meetings did not have all required staff present.
Failure to monitor antibiotic use: The IP/MDS Coordinator stated the facility did not have an Antibiotic Stewardship Program and only tracked which residents received antibiotics for QAPI, with no tracking of antibiotic use or infection trends. The DON acknowledged there was no infection or trend tracking, and the facility assessment and IPCP policy referenced infection prevention and antibiotic stewardship elements such as culture reports, sensitivity data, antibiotic usage reviews, and feedback to practitioners.
Failure to offer and document COVID-19 vaccination for staff: An RN and a CNA stated they were not offered the COVID-19 vaccine and were not asked about their vaccination status. The IP/MDS Coordinator stated the facility had never offered staff COVID-19 vaccines, staff were not educated outside of an annual competency fair, and there was no policy or documentation for employee vaccine administration, screening, education, or current vaccination status. Employee file review found no record of vaccine education or offers, and the DON stated she did not know whether these requirements applied.
The facility failed to provide ongoing, understandable education on Resident Rights to its residents and/or their representatives. During a Resident Council meeting, residents reported they were unaware of having rights, did not know what those rights were, and did not know if they were posted in the facility. Review of several months of Resident Council minutes showed that leadership attended but did not provide Resident Rights education. The Life Enrichment Director acknowledged that staff had not been reviewing or educating residents on their rights during these meetings, and the DON stated that Resident Rights were only given at admission and not reviewed on an ongoing basis. Neither could confirm that Resident Rights were posted and readily available, despite facility policy requiring that residents be informed of their rights and that these rights be posted throughout the facility.
Surveyors found that multiple residents who required staff assistance with oral hygiene, toileting, and repositioning did not consistently receive this care and that it was not documented as required. Several residents with cognitive impairment or physical limitations, including those with multiple sclerosis, had care plans specifying staff assistance with oral care, yet their records contained no oral care documentation, and one resident’s room lacked oral care supplies. Residents and family members reported that oral care was rarely provided, that a resident often had food on her face and mouth, and that one resident had to use an alarm to prompt staff to reposition her and reported not being changed overnight despite urinary incontinence. Staff interviews confirmed that oral care was expected twice daily per facility policy, but also revealed frequent findings of residents with unclean faces and hands after meals.
A facility failed to prevent accidents and injuries by allowing a resident with moderate cognitive deficit to be pushed a long distance in a manual w/c without footrests while observed by nursing staff, and another resident with severe cognitive impairment to be pushed with feet dragging on the floor. Two dependent residents who required full body mechanical lifts reported or were described as being transferred either with only one staff or without the lift at all, with multiple CNAs and nurses acknowledging that single-staff lift transfers occurred despite the expectation for two-person assistance. Additionally, monthly hot water temperature logs showed elevated readings in some areas and stopped being recorded, while the plant operations director, DON, and administrator each admitted they did not know the appropriate temperature parameters for resident use and had no policies in place for water temperature, mechanical lift use, or wheelchair transport safety.
Failure to Provide Dignity and Respect Residents reported and surveyors observed multiple instances of undignified care and disrespectful staff behavior. A resident was pushed partially exposed in a w/c to the shower room, another resident reported being called names and spoken to rudely when asking for help, and a family member described staff as demeaning and undignified during toileting care. One resident was also observed sitting alone in the dining room calling for help while waiting for food. Other residents reported being left in soiled briefs, not being repositioned as ordered, staff refusing to wear gloves during care, staff going through personal belongings, and a staff member confronting a resident about speaking with surveyors. The DON and other leaders stated residents should be treated with dignity and respect and that grievances should be completed when concerns are voiced.
Survey results and complaint/investigation records were not readily available to residents and their representatives. The Survey Binder did not contain 3 years of surveys or complaints, and the survey results book at the LTC entrance contained only one CMS 2567. During Resident Council, residents did not know where recent State Inspection documents and plans of correction were kept, and the DON and Life Enrichment Director could not explain the process or who maintained the book. The facility also could not produce a policy for keeping survey results available.
The facility failed to notify the physician and resident representatives/family/POA when a resident developed a head hematoma and when multiple residents had new or worsening wounds. Records showed delayed or missing physician notification for a heel DTI, a diabetic toe ulcer, worsening sacral pressure injuries, and an unstageable sacral wound, with inconsistent wound assessments and missing measurements/photos. Staff and the DON acknowledged several wounds worsened without timely escalation, and that the head injury was not promptly reported to the physician or family.
A facility failed to keep resident rooms clean and homelike and failed to complete personal inventory sheets for several residents. One resident with intact cognition reported a dirty bathroom, debris on the floor, and missing clothing after staff were seen going through her belongings, while another resident reported missing glasses and no inventory list was available. Family complaints and staff interviews also described dirty floors, missing supplies, and rooms that were not being cleaned daily.
Failure to document and process resident grievances: Two residents with intact cognition voiced repeated concerns about overnight care, incontinence care, repositioning, staff conduct, and missing personal items, but no grievance was documented for either resident. Residents and staff stated they did not know what a grievance was or where forms were located, and the posted grievance information referenced forms that were not available. Staff interviews showed concerns were discussed informally, but the facility did not document or clearly process the complaints.
Failure to Complete Further Background Checks Before Hiring RN with License Probation: The facility hired an RN after a license verification showed adverse action and probation in multiple states, including probation related to medication-related errors. The employee file lacked documentation of further research to confirm whether the RN could work at the facility, despite the facility policy stating it would not knowingly employ individuals with certain disciplinary actions against their professional license.
Failure to complete required background checks and fully investigate abuse concerns. Staff files showed background checks and license verification were completed after hire, and one RN’s file contained a background check note for further research plus license probation history, but no documentation showed the additional review was completed. Staff also reported concerns that an RN was improperly handling narcotics and back-charting medication administration, yet the ADON and DON did not fully investigate the reports or interview staff involved.
A facility failed to thoroughly investigate narcotic discrepancies after an RN signed out oxycodone for a resident who denied receiving it, and staff later raised repeated concerns that the RN was documenting PRN pain meds as given without actually administering them. The DON and ADON acknowledged they noticed the pattern but did not look further into it, and a separate hydromorphone shortage for another resident also lacked staff and resident interviews. The record showed the affected residents had pain-related diagnoses and mild cognitive impairment, and the facility’s investigative file was incomplete.
No CPR-certified staff coverage was maintained at all times. The DON stated there was no CPR certification list and no way to plan 24-hour CPR coverage, and the interim DON said CPR coverage was not being assessed around the clock. The scheduler stated she had little training, was unaware CPR coverage was required, and did not schedule RN coverage for that purpose. Review of staff schedules showed no CPR coverage for 283 shifts, and an RN stated the facility had not asked for his CPR certification until the survey date.
Failure to provide drinks during meal service. Residents were seated in the dining room with no drinks on the tables while lunch was being served. A dietary aide brought a drink cart partway through the meal, but several residents still had no beverages with their trays, and some residents had to get drinks for themselves or ask for them. The DON stated CNA staff were responsible for distributing drinks during meals, while dietary staff were supposed to do so, and the facility policy said nurses' aides would provide and encourage meal fluids.
Insufficient nursing staffing and RN coverage led to inconsistent resident care and delayed transfers. Facility schedules showed multiple shifts with only one nurse, only CNAs, or no RN present for 8 consecutive hours, despite leadership stating the building should have 2 nurses or a nurse and med aide with 3 CNAs on day and evening shifts and 1 nurse with 2 CNAs overnight. A resident who required a full-body mechanical lift reported that staff sometimes used only one staff member for transfers, and a CNA stated residents could wait 30 to 40 minutes for help with lift transfers because the facility did not have enough staff.
The facility failed to provide orientation for newly hired staff and agency staff. A CNA reported being placed on the floor without training or an orientation checklist, and another CNA said he received no formal training and was only paired with other staff for a few days. The ADON, LPN/MDS Coordinator/IP, and DON acknowledged there was no orientation packet or checklist for new hires or agency staff.
RN coverage was not maintained for 8 consecutive hours each day. Schedule review showed multiple days when no RN was present for the full required period, and staff interviews confirmed the scheduler was unaware of the RN coverage requirement, the interim DON mainly worked weekdays, and there were weekends with no RN coverage. The Facility Assessment listed RN hours on day and evening shifts but 0 RN hours on night shift.
Failure to complete annual employee performance reviews was identified after staff interviews and record review. A CNA stated she had never received a performance evaluation since starting at the facility, another CNA/Interim Social Services Director stated she had not had an evaluation in over a year, and an RN stated he had not had a performance review since 2021. Review of the RN's personnel file documented no performance evaluations, despite the facility assessment stating employees are provided an annual performance appraisal.
Insufficient food and nutrition staffing and poor coordination led to delayed meal service, incomplete temperature monitoring, and failure to follow ordered diets. Residents reported late meals, cold food, and missing items such as silverware and drinks, while staff were observed serving uncovered desserts, delaying breakfast and lunch, and delivering meals without proper meal ticket matching or diet modifications. The RD and DON acknowledged problems with menu compliance, therapeutic diets, food temperatures, and meal delivery timing.
Failure to Follow Approved Menu and Therapeutic Diet Portions: Dietary staff did not follow the approved noon meal menu for residents on regular, mechanical soft, CCHO, liberal renal, and puree diets. Dinner rolls were not served as listed, desserts were pre-plated without differentiating portions for therapeutic diets, and puree residents received applesauce instead of the approved fruit crumble. The RD and kitchen services CEO stated staff were expected to prepare meals as directed on the menus and obtain approval for substitutions.
Food and drink were not consistently served at safe, appetizing temperatures for multiple residents. Several residents with BIMS scores ranging from 11 to 15 reported that room trays were lukewarm or cold, and observations showed hot items below the facility’s 135-degree standard and cold items above the 41-degree standard. An RD confirmed the temperature standards, and an LPN documented trays left in residents’ rooms, including trays left in front of sleeping residents and one resident left hunched over a tray in bed.
Meal service was delayed and food was handled and stored unsafely. Residents reported unpredictable meal times and room trays arriving late, with some food served lukewarm or cold. Surveyors observed uncovered desserts being moved between the kitchen and dining room, staff touching cup rims and handling bread with bare hands, and a room tray with a dessert at 56 degrees. The kitchen also had incomplete temp logs, missing thermometers, expired and unlabeled food, dirty storage areas, and staff not consistently following hand hygiene, glove, or beard-net practices.
Improper disposal of room trays, food waste, and garbage was observed throughout the facility. Trays with leftover food and beverages were left in halls, cubbies, and by the nurse’s station for hours and sometimes until the next day, including trays with prior-day meals and uncovered food items. Kitchen observations also found expired and undated food in the walk-in refrigerator, dirty dishes left on counters, and items placed on and beside an overflowing uncovered garbage can near the food transport area.
A facility failed to keep complete and accurate records and to safeguard resident information. An RN documented PRN pain meds and tube flushes before or without completing them, a laptop with an open EMR was left unsecured during care, personal property inventories were missing for residents reporting lost belongings, and kitchen temp and cleaning logs had multiple missing entries that were later filled in with the same initials.
Staff failed to follow infection control practices during wound care, catheter care, transfers, and equipment handling. Observations showed missed hand hygiene, improper glove and gown use, a CNA leaving a room still wearing PPE, a catheter drainage bag placed in a recliner pocket, shared equipment not sanitized after use, and oxygen tubing lying on the floor. The DON and IP also stated the infection prevention and control program had not been reviewed annually and the facility was not tracking infections, infection rates, or antibiotic use.
Two residents did not receive appropriate assessment and care according to orders and clinical needs. One resident with intact cognition had a diabetic ulcer on a toe that was present on admission but was not identified on the admission skin assessment, and no wound assessment, physician notification, or treatment occurred for about a week until an RN documented and initiated ordered care. Another resident with near-intact cognition had a head injury first seen as a red mark on the forehead; the LPN obtained vitals but did not initiate neuro checks, fully assess for additional injuries, or promptly notify the DON, physician, or family. Neuro assessments and provider notification were delayed until the area became a hematoma later in the day, and additional bruising on the hip and shoulder was only discovered after transfer to the ED.
Failure to provide SNF ABN with NOMNC. The facility did not give the SNF ABN CMS-10055 to three residents after their NOMNCs indicated Medicare coverage for skilled nursing services would end, and it used an outdated NOMNC form instead of the current CMS version. The Interim DOSS said she had been trained that the SNF ABN was only completed in certain situations and was using a modified form from the prior director, while the Administrator was unaware the SNF ABN was not being used with the NOMNC.
A staff member repeatedly signed out and gave PRN opioid pain meds to residents without consistent resident request, including one resident who denied asking for the medication and another whose controlled substance record showed a 3 mL discrepancy. The residents involved had pain-related diagnoses and varying cognitive status, and the staff member admitted she was giving pain meds prophylactically, even when residents did not ask for them.
Failure to Obtain Bed Hold Notifications: The facility failed to obtain bed hold forms for two residents who were transferred to the hospital. One resident became hypotensive, weak, dizzy, and nauseated during therapy and was later admitted for declining renal function, while another resident with intact cognition left for the ED with elevated pulse, increased pain, and nausea. Although the bed hold policy was documented as given to the resident, the facility later confirmed no completed bed hold form was available for either hospitalization.
Inaccurate MDS coding affected one resident’s discharge assessment type and two residents’ medication coding. The MDS for one resident documented conflicting assessment status after reentry, while MDSs for two residents inaccurately indicated they were not taking an antipsychotic despite a physician order for Rexulti and a care plan noting psychotropic use for behavior management. The DON said the MDS Coordinator oversaw accuracy, and the MDS Coordinator said the issue may have been a census issue and was unsure how the antipsychotic was missed.
Failure to Complete Baseline Care Plans Within 48 Hours: Two residents with moderate cognitive impairment did not have Baseline Care Plans completed and documented within the required timeframe. One resident had COPD, heart failure, A-fib, and oxygen use; the other had diabetes, recent UTI, fall history, and prior stroke history. EMR review showed no timely progress note documentation, no resident or representative signatures, and both residents stated they did not know about any care plan conference. Staff reported the conferences were delayed and not held as required, with one conference occurring late and another not yet scheduled.
Failure to provide resident-centered activities: A resident with moderate cognitive impairment, incontinence, and dependence for bed mobility and transfers was repeatedly observed seated in a wheelchair in the day room/living room with no activity or stimulus, including facing a blank TV screen and wall. Staff attempted to turn on the TV but left without offering another activity, and the care plan did not identify person-centered activities. The DON and Administrator acknowledged residents should not be left without engagement, and the Administrator stated there was no activities policy.
Improper Enteral Tube Flush Administration: A resident with an enteral tube and intact cognition had an order for water flushes, but an RN was observed checking tube placement and then pushing the flush into the tube with a piston syringe instead of allowing it to flow by gravity. The DON stated staff should not push meds or flushes through enteral tubes and that flushes and meds should be given by gravity, while also noting the facility enteral nutrition policy did not address gravity administration.
A resident with COPD, heart failure, A-fib, and dementia did not receive oxygen therapy in accordance with the physician order for 2 L/minute. Staff observed the concentrator set at the wrong flow, the nasal cannula disconnected, and the tubing on the floor; later, the resident's E-Tank was not turned on and the regulator was set incorrectly. The resident stated the oxygen had been an ongoing issue since admission and that she had a hard time catching her breath when the oxygen was not set up properly.
Failure to Serve Ordered Diet Consistencies: Staff did not prepare and plate meals according to ordered diet textures for multiple residents with cognitive impairment and swallowing/nutritional needs. During meal service, a cook partially modified noodles, served regular chicken with the meal, and sent out fruit crumble and other items without the required texture modifications or clear meal identification. Interviews confirmed diets were expected to match MD orders and approved menus, but meal tickets were not used to verify the correct plates.
Therapeutic diet orders were not followed for multiple residents with diabetes and renal needs. A resident with severe cognitive impairment and a resident with renal insufficiency and dialysis needs did not consistently receive ordered diet items, while meal service for another resident showed staff did not consistently use meal tickets and served portions that did not match the approved CCHO and renal menus. The RD stated cooks were to follow the menus and therapeutic diets had to be followed.
Surveyors found that the facility failed to follow physician orders for medication administration, including not administering prescribed medications, giving medications outside of ordered parameters, and not documenting required monitoring. In several cases, staff did not notify the primary care provider when a resident refused multiple medications over several days, and medications were administered or withheld without proper documentation or physician approval.
Three residents with indwelling catheters did not receive catheter care and monitoring as required, with multiple missed entries for catheter output and failure to report changes in eating patterns that could indicate UTI. One resident was hospitalized with severe sepsis due to UTI, and another was admitted for a complicated UTI. Nursing staff and leadership confirmed that missing documentation meant care was not completed, and facility policy required regular documentation and reporting of unusual findings.
Surveyors found that staff did not consistently follow Enhanced Barrier Precautions or perform required hand hygiene during high-contact care activities for two residents with indwelling catheters and wounds. Staff failed to wear gowns during transfers and grooming, and did not always perform hand hygiene between glove changes, despite facility policy and posted instructions.
The facility did not consistently update care plans with new fall prevention interventions after residents experienced multiple falls, and failed to complete or document required neurological assessments following unwitnessed falls. Several residents with cognitive impairment and fall risk were affected, and staff interviews revealed inconsistent practices and lack of access to current policies.
The facility did not update its Facility Assessment after a change in ownership, continuing to use an outdated document with the previous facility name. The current Administrator confirmed no updated assessment had been completed, and the ADON was unable to access or locate relevant policies. Corporate staff did not provide requested policy information after being contacted.
The facility did not employ a qualified Infection Preventionist (IP) as required, with the designated IP and DON both still in the process of completing necessary training. The antibiotic stewardship program was not current, and staff were unclear about the IP's qualifications. Corporate support was limited to remote assistance, and updated policies from new ownership were not provided when requested.
Surveyors found that the facility did not maintain a clean environment, with dead insects remaining in a hallway for several days and a resident's room and bathroom left uncleaned despite family concerns. Housekeeping was expected to clean daily, but debris and stains persisted, and staff denied receiving complaints about cleanliness.
Failure to Prevent, Assess, and Manage Pressure Ulcers and Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention, assessment, and treatment, and to prevent the development and worsening of pressure ulcers for multiple residents, most extensively documented for Resident #29. Resident #29 was admitted without pressure ulcers and initially assessed with a Braden score of 20 (not at risk), later decreasing to 16 (at risk) and then to 9 (very high risk). An in-house acquired Stage 2 sacral pressure ulcer was first documented on 11/28/25 with measurements, and again on 12/6/25 with increased size. On 12/16/25, the wound was documented as a Stage 2 ulcer but without any measurements. From 12/16/25 through 1/3/26, there were no complete wound assessments with measurements, descriptions, or photos, despite ongoing skin check entries that noted a pressure injury on the coccyx/sacrum without measurements or detailed description. During this period, the care plan did not reflect new or updated interventions in response to the in-house acquired Stage 2 ulcer or its deterioration. Resident #29’s wound worsened significantly without timely or adequately documented provider notification or changes in treatment. Infection documentation from 1/1/26 through 1/5/26 noted a sacral ulcer infection with odor but lacked measurements, wound description, and MD notification. On 1/3/26, an unstageable sacral pressure ulcer with slough/eschar, strong odor, and a much larger area was documented. A subsequent 1/5/26 skin and wound evaluation described an unstageable ulcer with slough/eschar and large dimensions, again without physician notification. The DON acknowledged that weekly wound assessments with measurements and descriptions were not completed between 12/16/25 and 1/3/26 and that the wound did not change from a Stage 2 to a large unstageable ulcer overnight. Interviews with nursing staff indicated that the wound had gotten larger and worse, that the NP was told it looked worse, and that treatment orders were not changed from 12/16/25 until the resident was seen at a wound clinic on 1/2/26. Hospital records later documented a sacral decubitus ulcer with foul odor, significant necrotic tissue, and debridement down to ligamentous structures and exposed bone. The deficiency also includes failures in basic preventive care such as repositioning and incontinence management for Resident #29. The resident, who had multiple sclerosis and could not reposition herself, reported that staff were not turning her every 2 hours as ordered and that she had to set an alarm on her phone to prompt staff. She stated that some overnight shifts only repositioned her once late in the night and that she had reported these concerns multiple times. Staff interviews corroborated concerns that the resident was not being repositioned appropriately and that CNAs had reported the wound was not improving but were told to apply cream without the nurse assessing the area. There were also reports that a CNA refused to change the resident’s saturated brief, allegedly stating there were no briefs and reapplying the same brief, while another CNA described only “freshening up” the resident and not returning later in the shift. The DON and nursing staff acknowledged that CNAs may not recognize or report early pressure injuries, that CNA reports to nurses were sometimes undocumented, and that “a lot of balls were dropped” regarding wound care. For Resident #2, the deficiency includes incomplete and inaccurate wound assessment and documentation, and failure to align the care plan with identified skin risks and conditions. Resident #2 was admitted with a Braden score of 17 and a documented need for repositioning at least every 2 hours, and had incontinence-associated dermatitis (IAD) on the buttocks present on admission. Wound evaluations showed large fluctuations in the documented size of the IAD over time, including a significant increase in area on 12/5/25 and later a marked decrease by 12/30/25, followed by another large increase on 1/6/26. The 12/12/25 wound evaluation lacked any measurements, and a photo from 1/6/26 showed two areas consistent with Stage 2 pressure ulcers on the sacrum/coccyx that were not documented as such in the record. The MDS identified that the resident was at risk for pressure ulcers and had MASD, and that interventions such as pressure-reducing devices and nutrition/hydration interventions were in place, but the care plan only reflected a generic potential for pressure injury and did not include the specific skin issues or interventions identified on the MDS. Interviews and record reviews further demonstrated systemic issues contributing to the deficiencies. The NP reported that she was shown a picture of Resident #29’s wound on 12/16/25 and then only heard again around Christmas via a text that the wound looked worse and needed a wound care visit; she did not receive updates on the wound clinic’s findings and was not informed when the wound became unstageable or significantly deteriorated. She stated she would have expected notification with such changes and that the wound appeared preventable and should not have progressed to its current state. Nursing staff acknowledged expectations to notify physicians of wound changes, lack of improvement, or deterioration, but also acknowledged that this did not occur consistently for Resident #29. The DON confirmed that physician notifications and wound assessments were missing or incomplete, that CNA reports were sometimes not documented, and that there were multiple failures in wound care practices across the facility. Overall, the documented actions and inactions include failure to perform consistent, measurable weekly wound assessments; failure to document and communicate wound deterioration and infection to providers; failure to update care plans and interventions in response to new or worsening pressure ulcers; failure to ensure regular repositioning and timely incontinence care; and failure to accurately identify and document pressure ulcers versus dermatitis. These failures affected multiple residents, with detailed evidence for Residents #29 and #2, and were acknowledged by the DON and nursing staff as significant lapses in wound care and skin integrity management.
Failure to Involve Residents/Representatives and Update Interdisciplinary Care Plans for Changing Clinical Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop, review, and revise comprehensive care plans with an interdisciplinary team that included residents and/or their representatives, and to update care plans when residents’ conditions changed. Multiple residents and family members reported that care plan conferences had not occurred since a change in facility ownership, despite prior practice of quarterly meetings. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and diabetes, had a baseline care plan and a signed POA document, but there were no care conference attendance sheets, and the family stated they had not been included in care plan meetings since the new company took over. Another cognitively intact resident and that resident’s son both reported they had never been invited to care conferences since admission, and the social services director acknowledged that many care conferences were not completed and that residents and families had not been part of quarterly assessments. The facility also failed to revise care plans to reflect significant changes in residents’ clinical status and treatment orders. One resident with intact cognition and a right femur fracture was being transferred with a whole body mechanical lift per therapy evaluation and documentation, but the care plan still listed stand-pivot transfers with one staff and a gait belt; staff reported they had not received updated transfer information and expected therapy to update the care plan. Another resident with moderate cognitive impairment and multiple diagnoses had a care plan with 19 focus areas whose interventions had largely not been updated since the prior year, despite the facility no longer offering restorative nursing services; there was no EMR documentation of care conferences or timely updates, and late entries were added to progress notes only after surveyor inquiry. A resident who experienced a fall, hospitalization, and diagnosis of Influenza A had a marked decline in transfer ability and required a full-body mechanical lift and transmission-based precautions, but the care plan was not updated to reflect the new transfer status or the need for PPE until after surveyor review. Additional failures involved skin integrity and catheter-related care planning. One resident admitted with a Stage 2 pressure ulcer and later placed on and then removed from an indwelling urinary catheter had care plan interventions that continued to reference catheter care and Enhanced Barrier Precautions for the catheter after the catheter was discontinued by physician order; the MDS showed the resident as incontinent without a catheter, but the care plan was not revised. Another resident at risk for pressure injuries developed in-house acquired moisture-associated skin damage on the buttocks and a deep tissue injury on the right heel, with multiple wound treatment orders and documentation of a scoop mattress and lack of repositioning aids; however, the care plan did not include MASD, the DTI, or related interventions such as pressure-reducing devices or nutrition/hydration measures. A different resident admitted without pressure injuries developed in-house Stage 2 pressure ulcers on the buttocks and a DTI on the right heel; the care plan contained no prevention focus, goals, or interventions until after the wounds occurred. Further, residents with existing or worsening pressure injuries did not have their care plans revised to reflect new or escalated needs. One cognitively intact resident with an in-house Stage 2 sacral pressure ulcer later required surgical debridement of a Stage 4 sacral ulcer with exposed bone and a wound vacuum; the care plan showed a generic focus on potential for pressure injury and an in-house Stage 2 sacral ulcer but no new interventions after the ulcer progressed and the resident returned from the hospital with a wound vac and more advanced wound status. Another cognitively intact resident at risk for pressure ulcers developed unstageable skin on 12/23, but there was no care plan update or added interventions for this finding. Interviews with the MDS coordinator, DON, RN staff, and social services indicated that the MDS coordinator was primarily responsible for building and updating care plans, floor nurses generally did not update care plans, and care conferences were not consistently scheduled or documented with IDT participation, residents, or families, resulting in multiple care plans that were outdated, incomplete, or not reflective of current clinical orders and conditions.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate PBJ staffing data for Quarter 4 2025 based on payroll and other verifiable and auditable information. The PBJ Staffing Data Report review showed the facility triggered for failing to submit data for the quarter and for having a one-star staffing rating. The facility reported a census of 28 residents, and the review included staffing schedules for July through January, along with interviews and a review of the facility assessment and PBJ reporting policy. Review of weekend and Monday through Friday staffing schedules showed multiple shifts with staffing patterns that did not match what staff described as the expected coverage. Staff interviews reflected that the facility was supposed to have RN coverage, CNA coverage, and in some instances a medication aide, with day and evening shifts expected to have more than one nurse and multiple CNAs. Staff also stated there were times when there was no RN coverage on Saturdays and Sundays, times when only one nurse was in the building, and occasions when the facility was short a CNA or nurse because of call outs. Staff O, the scheduler, stated she was not aware of RN coverage requirements for daily hours or 7 days a week and was not aware of CPR coverage requirements in the building. The Administrator acknowledged the PBJ was not being submitted correctly because the corporate data pull reflected the wrong employees in the wrong area of the building, with Assisted Living and memory care staff being recorded on the SNF side and some SNF staff being recorded on the AL and memory care side. The Administrator also stated the facility assessment staffing numbers were approximate and not minimums. The facility assessment documented direct care staffing hours per resident day of 0.33 RN, 0.33 LPN, and 0.67 CNA on day shift and evening shift, and 0 RN, 0.33 LPN, and 0.67 CNA on night shift. The facility policy stated staffing and census information would be reported electronically to CMS through PBJ based on payroll records or other verifiable information.
Repeated QAPI and PIP Deficiencies
Penalty
Summary
The facility failed to demonstrate good faith attempts to correct repeated quality deficiencies identified across multiple surveys over the last year, including F-880 infection prevention and control, F-584 safe/clean/comfortable/homelike environment, F-657 care plan revision, F-684 quality care, F-686 treatment of pressure ulcer, F-725 sufficient nursing staff, F-842 resident records, F-550 resident rights/exercise of rights, F-641 accuracy of assessments, F-812 food procurement/store/prepare/serve-sanitary, and F-689 free of accidents and hazards. Review of prior CMS Form 2567s showed repeated deficiencies on the current survey, with F-684 and F-812 identified as repeat deficiencies on 3 of the last 4 standard health surveys, and F-550, F-689, and F-725 identified as repeat deficiencies on 2 of the last 4 standard health surveys. The facility census was 28 residents. Clinical record review on 1/29/26 at 12:20 PM found no QAPI policy in place describing how the facility would identify, report, track, investigate, and analyze adverse events or problem-prone concerns, how it would obtain and use feedback from resident representatives, or how it would monitor the effectiveness of performance improvement activities to ensure sustained improvement. On 1/29/26 at 12:23 PM, the Administrator stated the QAPI committee had reviewed the deficiencies but had not been very good at developing PIPs around the concerns, that the facility had been building its own policies as it went, and that no QAPI policy or current PIPs existed. The Administrator also stated the committee did not feel the audits were not working, but there probably could have been adjustments, and believed training or performance was causing the repeated concerns. Review of the facility assessment for the infection prevention and control program documented that the facility must conduct a facility-based and community-based risk assessment and that gaps and issues should be identified and adapted to QAPI programs.
Missing QAPI Policy and Performance Improvement Plans
Penalty
Summary
The facility failed to properly establish and implement written policies and procedures for its QAPI plan and failed to properly monitor, measure, and track performance to ensure improvements were realized and sustained. Clinical record review on 1/29/26 at 12:20 PM revealed no QAPI policy in place describing how the facility would identify, report, track, investigate, and analyze adverse events or problem-prone concerns, how it would obtain and use feedback from resident representatives to identify high-risk or problem-prone issues, or how it would monitor the effectiveness of performance improvement activities. The review also found no PIPs developed to track or ensure improvements. On 1/29/26 at 12:23 PM, the Administrator stated the facility had reviewed deficient practices from state surveys but had not been very good at developing PIPs around the concerns. The Administrator stated he had reached out to corporate office for help and that they did not have a long term care skilled consultant for assistance. He acknowledged the facility had been building its own policies as it went, did not currently have a QAPI policy, and did not have any PIPs. He further stated the facility had not developed any PIPs since he had been employed there. Review of the Facility Assessment showed the facility was to conduct a facility-based and community-based risk assessment, identify gaps and issues to be adapted to QAPI programs, and evaluate policies and procedures annually or more often as needed.
QAA Committee Did Not Meet With Required Members
Penalty
Summary
The facility failed to have the minimum members of the Quality Assessment and Assurance (QAA) committee meet quarterly. The facility reported a census of 28 residents. Document review showed that the QAPI attendance records for 4/17/25 did not include the Infection Preventionist, the 7/17/25 meeting did not include the Medical Director, the 8/28/25 meeting did not include the Medical Director or Infection Preventionist, and the 10/23/25 meeting did not include the DON or ADON. During record review on 1/29/26, no QAPI policy was found describing how the facility would identify, report, track, investigate, and analyze adverse events or problem-prone concerns, how it would obtain and use feedback from resident representatives to identify high-risk or problem-prone issues, or how it would monitor the effectiveness of performance improvement activities to ensure improvements were sustained. On interview, the Administrator stated QAPI should meet at least quarterly, identified the invited members, acknowledged that 1 or 2 meetings did not have all required staff present, stated the Medical Director missed a quarter, acknowledged the DON or ADON was not available for a quarter, and stated the facility did not currently have a QAPI policy.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to develop and implement a facility-wide system to monitor protocols and the use of antibiotics prescribed to residents. During an interview, the Infection Preventionist/MDS Coordinator stated she had been in the IP role since June 2025 and reported that the facility did not currently have an Antibiotic Stewardship Program. She stated that antibiotic use was being reviewed for residents prescribed antibiotics by physicians, but for quarterly QAPI meetings she only kept track of the residents who were prescribed antibiotics for the quarter and did nothing further. She also stated that management discussed lab culture results in daily morning meetings, but she did not track antibiotic use or infection trends. During an interview, the DON stated she expected corporate office to provide updated infection control and antibiotic stewardship policies according to federal regulation. She acknowledged the facility did not currently have tracking for infections or trends and stated that without tracking the facility could not find trends. Review of the Facility Assessment dated July 14, 2025, showed infectious diseases were included among common diagnoses/conditions and that the Infection Prevention and Control section addressed identification and containment of infections. Review of the undated Infection Prevention and Control Program policy stated that antibiotic stewardship included culture reports, sensitivity data, and antibiotic usage reviews in surveillance activities, that standardized infection criteria were used, and that antibiotic usage was evaluated with feedback provided to practitioners.
Failure to Offer and Document COVID-19 Vaccination for Staff
Penalty
Summary
The facility failed to offer COVID-19 vaccinations and failed to provide education regarding the benefits of vaccination to facility employees. During interviews, an RN and a CNA each stated they had not been offered a COVID-19 vaccine at the facility during the last year, and both stated the facility did not ask about their recent COVID-19 vaccination status. The Infection Preventionist/MDS Coordinator stated the facility had never offered COVID-19 vaccines to staff and that staff were not educated about COVID-19 outside of an annual competency fair that included mask fitting. The Infection Preventionist also stated the facility did not have a policy for employee COVID-19 vaccine administration, documentation, or education, and acknowledged there were no documents to review for staff vaccine administration, screening, education, or current COVID-19 vaccination status. Review of employee files found no record of offering education or vaccinations to employees. The DON stated she did not know whether staff screening, education, vaccine offering, and current COVID-19 vaccination status were required and expected corporate office to provide an updated employee vaccination policy. The facility policy reviewed stated that infection prevention and control measures included encouraging staff, residents, and visitors to remain up to date with COVID-19 vaccine doses and providing resources and counseling about the importance of receiving the COVID-19 vaccine.
Failure to Provide Ongoing, Understandable Education on Resident Rights
Penalty
Summary
The facility failed to provide ongoing education to residents and/or their representatives on Resident Rights in a format that was understandable to them. During a Resident Council meeting, residents present reported they were unaware that they had rights, did not know what their Resident Rights were, and did not know if these rights were posted within the facility. Review of Resident Council minutes for three consecutive months showed that various facility leaders attended the meetings but did not provide education on Resident Rights. During the same Resident Council meeting, the Life Enrichment Director stated she typically led the council and that an Activity Coordinator filled in when she was unavailable, and she acknowledged that staff had not been reviewing or educating residents on Resident Rights during these meetings. The DON stated that Resident Rights were provided only as part of admission packets and agreed they needed to be reviewed with residents on an ongoing basis, and neither the Life Enrichment Director nor the DON could confirm that Resident Rights were posted and readily available for residents, despite the facility’s Resident Rights policy stating that residents were to be informed of their rights and that these rights were to be posted throughout the facility. No specific resident medical histories or clinical conditions were described in relation to this deficiency, and the census at the time was 28 residents.
Failure to Provide and Document Oral Care, Toileting, and Repositioning for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required assistance with oral care, toileting, and repositioning for multiple dependent residents. For Resident #22, the Quarterly MDS dated 10/31/2025 showed a BIMS score of 4, indicating severe cognitive impairment, and documented a need for substantial/maximal assistance with oral hygiene. Her care plan, revised 11/18/2020, identified an ADL self-care performance deficit related to multiple sclerosis and required one staff to assist with daily grooming, including personal hygiene and oral care. A handwritten sign in her room requested that staff brush her teeth every day, and her emergency contact reported that her teeth were sometimes not brushed much when she visited, stating the resident would allow staff to complete oral care. On interview, the resident stated staff had not brushed her teeth that morning. The DON later stated she was unaware of the sign and that oral care should be completed at least twice a day, ideally by CNAs but also by nurses or other clinical staff, and possibly during OT. Resident #2’s MDS documented a BIMS of 15, indicating no cognitive impairment, and a need for supervision or touching assistance for oral hygiene. Her care plan, initiated 12/5/2025, documented that she required assistance of one staff for oral care. Review of her EHR showed no documentation of oral care provided. In interview, she stated she had a toothbrush in her bathroom and that whether oral care was provided depended on the staff. She reported that her husband helped her brush her teeth in the evenings, OT used to help her when she was going to therapy, and that occasionally a CNA would assist her with oral care. Resident #3’s MDS showed a BIMS of 11, indicating moderate cognitive impairment, and a need for partial/moderate assistance with oral hygiene. Her care plan, initiated 4/12/2025, documented that she required assistance of one staff for oral care, yet her EHR contained no documentation of oral care. Observation revealed no toothbrush in her room, and the ADON confirmed there was no equipment available to provide oral care. A CNA stated she had completed oral care that morning, claimed she obtained a new toothbrush for the resident every day, and said the resident only required set-up according to the care plan, which conflicted with the documented need for assistance. Resident #29’s MDS documented a BIMS of 15 and a need for supervision or touching assistance for oral hygiene, and her care plan dated 11/19/2025 indicated she required assistance of one for oral care. Her EHR contained no documentation of oral care. She reported that she had to set an alarm on her phone to ensure staff came to reposition her every two hours as ordered by her doctor, and that prior to a hospital stay staff were not repositioning her every two hours, with some overnight shifts only repositioning her at 3:00 or 4:00 AM. She stated she had multiple sclerosis, could not reposition herself in bed, and required staff assistance. She also reported that staff rarely provided oral care, that she could not sit up in bed on her own, and that she would appreciate staff assistance with oral care. She further stated that on one night a CNA refused to change her brief, that she was out of briefs and remained incontinent of urine without being changed all night, and that this CNA only repositioned her but did not change her. She reported prior concerns about this CNA’s care and described feeling treated without appropriate dignity or respect when requesting to be cleaned and changed. Resident #30’s MDS documented a BIMS of 13, indicating no cognitive impairment, and a need for substantial/maximal assistance with oral hygiene. Her care plan, initiated 12/3/2025, documented that she required assistance of one for oral care, yet her EHR contained no documentation of oral care. Her daughter reported that when she visited at random times, she frequently found food on the resident’s face and mouth and that it appeared her mother’s teeth had not been brushed. Staff interviews confirmed expectations and practices related to oral care: the ADON stated it was an expectation that all residents receive oral care even if they do not have teeth, and that dentures should be cleaned or soaked overnight. The DON stated oral care should be completed or offered and documented if refused, and that the required assistance should be reflected on the care plan. A CNA described asking cognitively intact residents when they wanted their teeth brushed and providing oral care before breakfast for residents who were not cognitively aware, and reported frequently finding residents with food on their faces and hands not cleaned from dinner, which she had brought to management’s attention. Review of the facility’s undated oral care policy showed that the purpose of the procedure was to keep lips and oral tissues moist, cleanse and freshen the mouth, and prevent oral infection. The policy required review of the care plan for special needs, assembly of needed equipment and supplies, and documentation in the medical record of the date and time mouth care was provided, the name and title of the person providing care, assessment data about the mouth, complaints of pain or discomfort, refusals with reasons and interventions, and the signature and title of the person recording the data. The policy also required CNAs to report to the licensed nurse for documentation. Despite these policy requirements and the care plan directives, surveyors found no documentation of oral care for multiple residents who required assistance, observed lack of oral care supplies in at least one resident’s room, and obtained resident and family reports that oral care, toileting, and repositioning were not consistently provided as needed.
Failure to Ensure Wheelchair, Mechanical Lift, and Hot Water Safety
Penalty
Summary
The deficiency involves the facility’s failure to prevent accidents and injuries related to wheelchair transport, mechanical lift use, and hot water temperature monitoring. For one resident with moderate cognitive deficit who used a manual wheelchair with staff assistance, a CNA pushed the resident approximately 240 feet through two hallways without wheelchair footrests in place. A nurse and another staff member observed and interacted with the CNA during this transport but did not stop the wheelchair movement despite facility expectations that residents must have footrests on before being pushed. Another resident with severe cognitive impairment, who was dependent on staff for manual wheelchair use, was observed being pushed by a CNA from the dining room to the living room with the resident’s feet dragging on the floor for about 75 feet, again without use of footrests. The facility also failed to ensure safe and consistent use of full body mechanical lifts for residents who required dependent transfers. One cognitively intact resident, fully dependent on staff for chair-to-bed transfers and care-planned for a full body mechanical lift with two staff, reported that some staff used only one person during lift transfers, while most used two. The resident, a nurse for 30 years, stated she knew two staff were required and that she had to ask staff to get a second person, expressing worry about ending up on the floor if the sling broke. Another resident with moderate cognitive impairment, also fully dependent for transfers, stated she did not like using the full body mechanical lift and instead grabbed staff around the neck while they placed her in the wheelchair, and that staff sometimes brought the lift into the room but then decided not to use it. Multiple staff interviews confirmed inconsistent and unsafe practices with mechanical lifts. One staff member stated he had been trained that lift use was based on manufacturer recommendations and that it could be used with only one person, and he reported concerns to an LPN without apparent follow-up. An RN reported seeing staff transfer residents requiring full body mechanical lifts with only one staff and stated that “all the staff do it all the time,” naming specific CNAs who frequently did so. Another RN acknowledged having to remind certain staff that two people were needed for full body lift transfers and that she had received reports of staff transferring residents alone. A CNA stated staff were not supposed to transfer residents alone with full body lifts but that when a nurse would not help, she transferred with only one staff. The facility further failed to protect residents from possible scalding injuries by not adequately monitoring and controlling hot water temperatures. Review of water temperature logs showed monthly readings in resident rooms and the laundry area, with some laundry temperatures documented above 140°F, and no temperatures recorded after mid-November. The Director of Plant Operations stated it was probably his job to review the temperatures monthly but admitted he did not do so and did not know what temperatures were too hot for resident rooms or showers, nor the appropriate high or low limits. The DON stated that 124°F for resident room water was “a little too hot” but was unsure of the correct temperature to prevent burns or the timeframe for burns to occur. The Administrator stated he was not a temperature expert, could not state the appropriate water temperature for showers or resident rooms, and was unsure whether the Director of Plant Operations had ever been trained on appropriate water temperatures. No policies were presented for appropriate water temperatures, full body mechanical lift use, or wheelchair transportation safety.
Failure to Provide Dignity, Respect, and Appropriate Resident Care
Penalty
Summary
The facility failed to provide residents with dignity and respect in multiple observed and reported situations. During an observation on 1/21/26, Staff I, a CNA, pushed Resident #7 partially exposed in a wheelchair through two hallways to the shower room until stopped by Staff H, an LPN/MDS Coordinator/Infection Preventionist, who directed the staff member to go back the other direction. Staff H, Staff D, Staff J, the DON, and the Administrator all stated residents must be fully covered when being transported to the shower room. Resident #7’s MDS showed a BIMS score of 11/15, use of a manual wheelchair, and need for partial/moderate assistance, with diagnoses including chronic kidney disease, aortic valve stenosis, and arthritis. Resident #17, whose MDS showed a BIMS score of 12/15 and diagnoses including A-fib, heart failure, dementia, and COPD, reported that when she voiced concerns about oxygen needs or needing help, staff responded with statements such as “calm down,” “we are going to get you,” and “you are a smart ass.” She also stated that when she asked for cold food to be reheated, she was told to be grateful she got food and the food was not reheated. Staff D, Staff J, the DON, and the Administrator stated residents should not be called names and their needs should be addressed when requested. Resident #33’s family also reported staff were extremely rude, including shutting the resident’s door when he asked it remain open and leaving him in soiled clothing after toileting assistance. Additional concerns involved Resident #16, Resident #15, and Resident #29. Resident #16 was observed sitting alone in the dining room before lunch, hollering for help and asking where her food was, with the food cart not brought in until later; the DON stated she was not sure why the resident was in the dining room alone that early. Resident #15, who had a BIMS of 15 and was on Enhanced Barrier Precautions requiring gown and gloves for high-contact care, reported being left in soiled urine and feces for hours, that staff did not take her to the bathroom overnight, that a CNA refused to wear gloves during care, and that a staff member went through her personal belongings. Resident #29, who had a BIMS of 15 and required assistance with toileting hygiene, reported staff refused to change her brief, did not reposition her every 2 hours as ordered, and confronted her about speaking with surveyors. Staff interviews reflected conflicting accounts, and the DON stated grievances were not being completed appropriately and that she would expect all residents to be treated with dignity and respect.
Survey Results Not Readily Available to Residents
Penalty
Summary
The facility failed to provide residents and/or their representatives accessible reports related to surveys, certifications, complaint investigations, and any plan of correction for the facility during the 3 preceding years. On 1/21/26 and again on 1/22/26, the Survey Binder did not contain 3 years of surveys or complaints. On 1/21/2026 at 11:47 AM, the survey results book located on a table to the right of the LTC entrance contained only one CMS Form 2567 with a survey end date of 6/13/2025. During the Resident Council meeting on 1/27/26 at 10:25 AM, residents present did not know that recent State Inspection documents and plans of correction were available for their review, and they did not know where those documents would be kept. Staff K, the Life Enrichment Director, and the DON were present during the meeting but could not provide additional information regarding the availability of the State Inspections for residents and/or their representatives. On 1/27/2026 at 11:02 AM, the DON stated she did not know who was responsible for keeping the survey results book up to date and was unsure whether the Administrator would do this. The facility was unable to produce a policy related to having survey results readily available.
Failure to Notify Physician and Family of Wound Changes and Head Injury
Penalty
Summary
The facility failed to notify residents’ representatives/family/POA and physicians of changes in condition for multiple residents when wounds worsened or when a head injury occurred. The report identified failures for residents with new or worsening skin breakdown, including residents with pressure injuries, diabetic foot wounds, and a head hematoma. The deficiency was based on clinical record review, resident and staff interviews, family interview, provider interview, and policy review. For one resident, records showed skin issues on admission, later development of a right heel deep tissue injury, and worsening sacral/buttocks breakdown that progressed from incontinence-associated dermatitis to a stage 2 pressure ulcer. Documentation showed inconsistent wound assessments, missing measurements, and a photo that revealed two undocumented stage 2 areas on the sacrum/coccyx. The DON stated the sacral wound should have been identified earlier, that the physician should have been notified when the wound changed, and that the deterioration would have been preventable with a change in treatment or appropriate identification of the wound change. For another resident, the admission skin assessment did not document a diabetic ulcer on the left second toe, and the wound was not assessed or treated until about a week later, when staff documented the area as present on admission and notified the physician. For a third resident, a sacral pressure ulcer worsened from stage 2 to unstageable with gaps in skin assessments, no documented measurements or photos for an extended period, and no physician notification documented when the wound enlarged. Staff and the DON acknowledged the wound did not deteriorate overnight and that the physician should have been notified of the worsening condition. A fourth resident developed an unstageable sacral pressure ulcer shortly after a skin check documented no skin issues, and the next assessment documented the wound without measurements or description. Staff acknowledged the wound likely existed before it was found and that it should have been discovered earlier. Another resident sustained a forehead hematoma/head injury, but the DON stated staff did not notify the physician or family appropriately when the injury was first found and neuro checks were not initiated at that time. The resident’s daughter/POA reported learning of additional bruising and injuries later at the hospital, and the DON stated she would have expected immediate notification of the physician and family when the head injury was noticed.
Dirty resident rooms and missing personal property inventories
Penalty
Summary
The facility failed to provide a clean, comfortable, homelike environment when resident rooms were observed with debris on the floor and bathrooms were not kept clean. Resident #15, who had a BIMS score of 15, reported that her bathroom had only been cleaned twice since admission, that she was the only person who had cleaned it, and that a bandage remained on the floor with feces on the toilet. Observations in her room on two separate days showed a bandage on the floor, brown splatter on the toilet riser, and white debris under the bedside table. Resident #15 also stated that popcorn had been on the floor since the prior week. The facility also failed to ensure personal property was protected because no personal inventory sheet was completed for Resident #15, Resident #30, Resident #38, and Resident #11. Resident #15 reported missing pants and shirts and stated staff had gone through her bag of belongings while another CNA was present. Staff interviews showed the concern had been discussed among nursing staff and laundry staff, but the DON acknowledged there was no personal property list for Resident #15 and did not know whether a grievance had been completed for the missing shirt. Resident #11, who also had a BIMS score of 15, reported missing reading glasses, and review of the inventory list showed no personal items list available. Resident #30, who had a BIMS score of 13, had repeated family complaints about housekeeping issues, including a dirty floor, no trash can liners, and no paper towels in the bathroom. Resident #38, who had a BIMS score of 15, was observed with copious amounts of white debris on the floor between the bed and recliner on two consecutive days. Staff interviews indicated resident rooms were expected to be cleaned daily, but staff also acknowledged that rooms were not being cleaned daily and that some rooms had not been cleaned since before the weekend. The Administrator later documented that there was no policy for environmental cleanliness.
Failure to Document and Process Resident Grievances
Penalty
Summary
The facility failed to honor residents’ right to voice grievances without discrimination or reprisal and failed to establish and follow a grievance process that documented concerns, made prompt efforts to resolve them, and made grievance forms available to residents, staff, and family members. During the resident council meeting, residents stated they were unaware of what grievances were, where to locate a grievance form, how to file one, or whether the facility responded to grievances. Observation of the grievance information posted near the entrance showed the policy referenced grievance forms at nursing desks and the front entrance, but no forms were available at that location, and multiple staff members stated they did not know where forms were kept. Resident #15 had a BIMS of 15 and reported multiple concerns to staff, including sitting in urine and feces for several hours overnight, repeated call light use without timely assistance, staff not taking her to the bathroom overnight, staff going through her personal belongings, and missing clothing items. She stated she had told many staff members, including the ADON, about the concerns. Staff interviews showed the concerns were discussed among staff, but no grievance was documented for the resident’s missing items or other complaints. One RN stated he did not write a grievance because the missing pants were found, while another CNA and laundry staff stated they had not been in-serviced on the grievance process and did not know where forms were located. Resident #29 also had a BIMS of 15 and reported that overnight staff were not repositioning her every 2 hours as ordered, that she had to set an alarm to prompt care, and that staff had refused to change her brief when she was incontinent of urine. She stated Staff EE treated her undignified and that she had voiced concerns about that staff member before. Staff interviews confirmed that Resident #29 had reported not being repositioned and not being changed appropriately, and staff discussed the concerns among themselves. Review of the facility’s grievance records showed no grievance documented for Resident #29, despite the resident’s voiced concerns and staff awareness of the issues.
Failure to Complete Further Background Checks Before Hiring RN with License Probation
Penalty
Summary
The facility failed to perform further background checks before hiring Staff A, an RN whose license verification showed adverse action and probation status in multiple states. The employee file showed a hire date of 9/8/2025, a Single Contact License and Background Check completed on 9/4/2025, and QuickConfirm license verification reports dated 9/4/2025 documenting that the RN license was on probation with adverse action by Nebraska, that action had been taken against the Nebraska nursing license, and that the Iowa license was on probation from 4/18/2025 to 4/18/2027 for error in prescribing, dispensing, or administering medication or sedation. The employee file did not contain documentation of further research to confirm whether Staff A could work at the facility despite the probationary findings. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated that it would not knowingly employ or otherwise engage any individual with a disciplinary action in effect against a professional license by a state licensure body as a result of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property.
Failure to Complete Background Checks and Investigate Abuse Concerns
Penalty
Summary
The facility failed to implement its abuse, neglect, exploitation, and misappropriation prevention program by not completing required background checks before staff were employed and by not following up on information that suggested further review was needed for a registered nurse. The facility’s policy stated it would not knowingly employ individuals with findings of abuse, neglect, exploitation, misappropriation of property, mistreatment, or disciplinary action against a professional license related to those issues. Review of Staff A’s personnel file showed the background check and license verification were completed after the hire date, and the background check indicated further research was needed. The file did not contain documentation showing that further research was completed to determine whether Staff A could work at the facility. Staff A’s license verification showed her RN license was on probation in Nebraska and that action had been taken against her nursing license, with additional probation history in Iowa related to error in prescribing, dispensing, or administering medication or sedation. Staff A’s file also lacked documentation showing the facility completed the additional review prompted by the background check. The Administrator stated that the background check company could only go back 30 days after a background check had been completed and that to resubmit it, Staff A would need to complete paperwork, but she was no longer employed at the facility. Staff interviews described concerns about Staff A’s handling of narcotics and medication documentation that were reported but not fully investigated. Staff D reported concerns that Staff A was the only staff member signing out a resident’s PRN oxycodone, that Staff A had accessed the medication room and narcotic box, and that a resident denied receiving pain medication that Staff A had documented as given. Staff J stated he observed Staff A documenting oxycodone administration without retrieving the medication from the narcotic drawer and later saw back-charting of narcotic administration times. Staff J said he texted the on-call scheduler with concerns, but management did not speak with him about them. The ADON acknowledged she did not look further into the concerns, and the DON stated the concerns were investigated only as to medication sign-out times, with no further investigation of the resident’s denial or the staff reports. The DON also stated she was not aware of a note sent to HR and that she did not interview staff members during the self-report investigation.
Incomplete investigation of narcotic discrepancies and staff concerns
Penalty
Summary
The facility failed to complete a thorough investigation after Staff A signed out Resident #3’s oxycodone as given, but the resident denied receiving the medication. Resident #3 had a BIMS score of 11, mild cognitive impairment, and diagnoses including stage 4 pressure ulcers, renal failure, and stroke. Her care plan addressed pain management and directed staff to administer medications as ordered and monitor effectiveness and adverse effects. The MAR showed multiple occasions when Staff A signed out oxycodone for Resident #3, including entries made during times when Staff A’s timecard showed she was on lunch break. During interview, Resident #3 stated she had not requested a PRN pain medication for a long time, usually declined when asked, and denied receiving a pain pill that morning. The investigation was also incomplete regarding concerns about Staff A raised by staff members in September and December. Staff D reported concerns that narcotics were being given multiple times a day to residents who never asked for pain medications, that there had been multiple narcotic count corrections, and that there had never been issues before the new employee. Staff J reported that on his first day training Staff A, she signed out Resident #3’s oxycodone but never retrieved it from the drawer, and he observed the same pattern with another resident. Staff Y reported hearing Resident #3 say she had not had a pain pill all day and that another resident denied receiving a pain medication that Staff A had signed out. The DON and ADON acknowledged they noticed Staff A giving a lot of pain medication and that they did not look further into the concerns. The facility also failed to investigate a missing hydromorphone discrepancy for Resident #32. Resident #32 had a BIMS score of 12, mild cognitive impairment, and diagnoses including acute respiratory failure with hypoxia, atrial fibrillation, heart failure, and renal failure. The MAR showed Staff A signed out hydromorphone 0.25 mL as given, but the controlled drug record later showed 3 mL missing from the bottle. The facility investigative file lacked staff and resident interviews related to this discrepancy. The DON stated she only interviewed Resident #3 for the self-report about the oxycodone concern, did not interview other residents or staff, and denied that an investigation was completed for the hydromorphone shortage.
No CPR-Certified Staff Coverage
Penalty
Summary
The facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not having a staff member on duty at the facility trained in CPR at all times. The facility reported a census of 28 residents. Review of the facility assessment showed that staff training, education, and competency considerations were to include staff certification requirements as applicable, but the facility did not have a CPR certification list available when surveyed. During interviews, the DON stated there was nothing available for CPR certification on any staff at the facility and that there was no list for CPR certified staff or way to plan 24-hour CPR coverage. The DON stated she expected the facility would have a list of CPR certified staff to ensure appropriate coverage. Staff P stated that when she was interim DON, there was no CPR list and CPR coverage was not being assessed 24 hours a day. Staff O, the CMA/CNA/scheduler, stated she had very little training before taking the position, was not aware of any required CPR coverage in the building, did not develop schedules to ensure RN coverage, and did not know CPR coverage was required when she made schedules. Review of facility staff schedules for the specified period revealed no CPR coverage for 283 shifts. Staff J, RN, stated the facility had not asked for his CPR certification until the survey date.
Failure to Provide Drinks During Meal Service
Penalty
Summary
The facility failed to provide drinks to residents during lunch service. During dining room observations, six residents were seated at tables and four residents were at assisted tables with two staff and a family member present, but there were no drinks on the tables. A therapist brought one resident to the dining room and asked if she wanted water, which she accepted. Later, a dietary aide brought a drink cart to the dining room and began handing out drinks to residents at the assisted tables, but drinks were still not on the tables for the other residents. As lunch continued, the dietary aide left the dining room and later returned with the food cart, delivering trays to residents who did not require feeding assistance. Residents continued to not have drinks at their tables. One resident propelled herself to the drink cart and got a can of pop, another resident went to the cart to get pop for herself and another resident, and a third resident asked the dietary aide for a pop. One resident received food but was not offered anything to drink, and another resident continued to have no drink at the table with lunch. The DON stated CNA staff were responsible for distributing drinks during meal service, while dietary staff were supposed to do so, and said residents should be offered what is available and told what to drink with their meals. The facility policy stated nurses' aides will provide and encourage intake of bedside, snack, and meal fluids on a daily and routine basis.
Insufficient nursing staffing and RN coverage
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. Facility schedules reviewed for multiple months showed several weekend and weekday shifts staffed with only one nurse, only CNAs, or no RN present in the building for 8 consecutive hours on numerous dates. The facility census was 28, and the Facility Assessment listed direct care staffing levels that included RN coverage on day and evening shifts, while the Administrator stated the assessment was only approximate and not a minimum requirement. Staff interviews showed the facility did not consistently staff to the levels described by nursing leadership. The scheduler stated she was not aware of any RN coverage requirements for daily hours or 7 days a week and did not develop schedules to ensure RN coverage. The DON stated there should be a minimum of 2 day nurses or a nurse and a medication aide with 3 CNAs, the pm shift should have the same staffing as the am shift, and the overnight shift should have 1 nurse and 2 CNAs. Staff also acknowledged several weekends with no RN coverage and shifts where staffing was short. Resident and staff interviews described delays and inconsistent assistance with resident transfers. A resident who required a full body mechanical lift stated staff sometimes used one staff member and other times two, and she worried about being left on the floor if the sling broke. A CNA stated the facility needed more staff because many residents required mechanical lifts and transfers could be delayed 30 to 40 minutes while waiting for a second staff member. Other staff stated there were times when only one nurse was in the building, including a shift when a nurse called out and no additional nurse responded, and the facility did not always have RN coverage on Saturdays and Sundays.
Lack of Orientation for New and Agency Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff with appropriate competencies and skill sets by not providing orientation for newly hired staff or agency staff. Based on facility document review, Facility Assessment review, and staff interviews, the facility reported a census of 28 residents and documented that staff training, education, and competency review were necessary to support the resident population. However, the facility did not have an orientation packet or checklist for newly hired staff or agency staff. Staff interviews confirmed the lack of formal onboarding. A CNA stated she had worked at the facility for about 4 months and did not receive an orientation checklist or any training when she started, describing that she was simply placed on the floor. Another CNA stated he also did not receive formal training, was only paired with other staff for a few days, and was not given a checklist or orientation packet. The ADON, LPN/MDS Coordinator/IP, and DON each acknowledged that new staff were oriented by other staff and that they were not aware of an orientation packet or checklist for new hires or agency staff.
RN Coverage Not Maintained for Required Daily Hours
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was present in the building for 8 consecutive hours each day. Review of staff schedules from 7/1/25 through 1/19/26 showed multiple dates when an RN was not present for 8 consecutive hours, including 8/23/25, 9/5/25, 9/12/25, 10/11/25, 10/25/25, 11/8/25, 11/18/25, 11/22/25, 11/23/25, 12/7/25, 12/20/25, 12/21/25, 12/28/25, 1/9/26, and 1/17/26. The facility reported a census of 28. The Facility Assessment documented RN hours per resident day as 0.33 on day shift, 0.33 on evening shift, and 0 on night shift. Interviews showed the scheduler was responsible for building schedules but stated she was not aware of any RN coverage requirements for daily hours or 7 days a week and did not develop schedules to ensure RN coverage. She stated there were days the facility was short a nurse because of call outs and that the interim DON worked Monday through Friday at least 8 hours but did not work weekends except when needed for an IV flush. An RN stated there were times when there was no RN coverage on Saturdays and Sundays, and on 1/17/26 he was the only nurse in the building after another nurse called out. The DON acknowledged a RN should be present in the building 8 consecutive hours a day every day, and the Administrator stated the staffing assessment was only approximate and that RN coverage on the evening shift was not required but only a possible need.
Failure to Complete Annual Employee Performance Reviews
Penalty
Summary
The facility failed to complete employee performance reviews at least once every 12 months. Based on facility assessment review, facility document review, and staff interviews, the facility reported a census of 28 residents and was found not to have annual performance appraisals completed for staff members. The facility assessment documented that employees are provided with an annual performance appraisal and potential merit pay increase at that time, and that policies and procedures are evaluated annually or more often as needed by the Administrator. During interviews, Staff R, a CNA, stated she had never had a performance evaluation since starting at the facility in 12/23. Staff N, a CNA and Interim Social Services Director, stated she had not had an evaluation in over a year and had only received evaluations when the previous owners ran the facility. Staff J, an RN who had worked at the facility for 6 years, stated he had not had any performance evaluations in the last year and had not had a performance evaluation since 2021. Review of Staff J's personnel file documented no performance evaluations.
Insufficient staffing and poor coordination caused delayed meal service and diet noncompliance
Penalty
Summary
The facility failed to provide sufficient food and nutrition service personnel with the competencies and skill sets needed to carry out food preparation, meal delivery, and timely meal service. During dining room observations, residents repeatedly stated that meals were late, breakfast was not served until 9:00 AM on one occasion, and food was often not hot when served or cold foods were not cold. Residents also reported that toast was not prepared correctly and that gravy was cold. Staff were observed moving uncovered desserts on and off a tray cart multiple times while traveling between the dining room and kitchen, and the dietary aide and dietary manager were not wearing name tags. During another breakfast observation, residents were waiting in the dining room without food service trays present, and one resident repeatedly asked for breakfast and for staff to bring the residents who required assistance so they could eat. No nursing or dietary staff were present in the dining room at that time. Assisted residents were not brought to the table until later, and breakfast was not fully served until 8:43 AM. At lunch, residents again waited for food and drinks, and several residents at both the assisted and regular tables did not have silverware or beverages when meals were delivered. One resident sat alone without silverware or drinks, another received lunch without silverware, and residents had to obtain drinks themselves from the cart. A resident also asked to leave because lunch service was delayed. Meal service observations also showed incomplete temperature monitoring and failure to follow diet orders and menu requirements. Temperature logs were incomplete for multiple refrigerators and freezers, and during lunch service the cook/dietary manager only checked temperatures for some items while failing to check others on the steam table. Mechanical soft diets were not properly modified, pureed diets were not consistently prepared as ordered, and regular menu items were used without the required alterations. Meal tickets were not matched to residents during service, room trays were missing, and one room tray was delivered more than an hour after meal service time. The Registered Dietitian stated that therapeutic diets must be altered to the appropriate consistency, temperatures must be within required ranges, and all food or drink items crossing a threshold must be covered. The DON acknowledged problems with coordination between kitchen and nursing staff, and the CEO for the contract kitchen company acknowledged concerns with meal delivery, missing meal tickets, diet noncompliance, temperature issues, and meal service taking longer than expected.
Failure to Follow Approved Menu and Therapeutic Diet Portions
Penalty
Summary
The facility failed to provide a well balanced diet that met residents’ nutritional and special dietary needs by not following the approved menu for a noon meal. During observation, the dietary staff prepared puree meals and mechanical soft plates, but the meal service did not consistently use meal tickets or resident completed menus to serve resident choices. The dietary staff also re-warmed pureed plates, placed meals on the warming shelf, and served pre-plated desserts without differentiating portions for the various diets served. The approved menu for regular, mechanical soft, liberal renal, and consistent carbohydrate diets included Chicken over noodles, vegetables, fruit crumble, and a dinner roll, but no dinner rolls were served to residents on those diets. For pureed diets, the menu called for pureed Chicken over pureed noodles, pureed vegetables, and pureed fruit crumble, but residents were provided applesauce instead of the listed dessert. The Registered Dietitian stated the cook needed to follow the menus as presented and contact her for approval if substitutions were needed, and the CEO for the kitchen services contract company stated kitchen staff were expected to prepare food as directed on the menus.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not consistently served at an appetizing temperature for 6 of 20 residents reviewed, including residents who ate in their rooms and residents who ate in the dining room. Resident #17, who had a BIMS score of 12/15 and was independent with eating, stated the food was not hot when it was supposed to be hot and said she had told staff the food was not hot. Resident #42, who also had a BIMS score of 12/15 and was independent with eating, stated her room trays had been cold when delivered. During observation, the final room tray delivered to Resident #42 was checked and the hot items were below the facility’s stated standard of 135 degrees, while a cold dessert item was 56 degrees. The RD stated hot foods must be served above 135 degrees and cold foods below 41 degrees. Resident #36, with a BIMS score of 13, stated food was often cold when it should be warm and that room trays were usually cold. Resident #44, with a BIMS score of 14, stated food was cold when it came on room trays; observation of a lunch tray delivered to the room showed a macaroni salad at 134 degrees and a mandarin orange fluff at 62 degrees. A staff LPN also documented that a resident had been left sitting in bed with a tray over her body and that meal trays had been left in front of sleeping residents hours after meals were over. Resident #3, with a BIMS score of 11, and Resident #15, with a BIMS score of 15, both stated their room-delivered meals were lukewarm or cold, and Resident #15 said staff sometimes reheated the food but not always.
Food Service Safety and Meal Delivery Failures
Penalty
Summary
Food was not prepared, served, distributed, and stored in accordance with professional standards. Residents reported delayed meal delivery and lukewarm or cold room trays. Resident #3, who had a BIMS of 11 indicating moderate cognitive impairment, stated her breakfast tray was just dropped off and that 9:30 AM felt late for breakfast because meals had come much later. Resident #9, who had a BIMS of 15, stated the timing of meals was unpredictable and that it was the facility’s biggest shortcoming. Resident #15, who also had a BIMS of 15, stated room meals were brought lukewarm and that she wished the food was served warmer; a CNA stated this resident had complained that hot food was cold and cold food was hot, and that room trays were being delivered late. Dining room observations showed uncovered desserts being transported back and forth between the kitchen and dining room while remaining uncovered, including multiple trips with trays of desserts left exposed on the cart. Staff also handled food and service items in ways that did not follow safe food handling practices, including a CNA removing bread from a bag with bare hands before placing it on a resident’s plate and feeding it to the resident, and staff touching the rims of residents’ cups while serving drinks. A documented room tray temperature check showed the entree and vegetables were within range, but the refrigerated dessert was 56 degrees, and the tray had been prepared more than 30 minutes earlier. The RD stated the final room tray temperatures were outside the required range and that the last room trays were delivered about an hour outside the meal service time. Kitchen and storage observations showed widespread sanitation, labeling, temperature monitoring, and food protection problems. The kitchen lacked internal thermometers in refrigeration units, temperature logs were incomplete, and multiple refrigerators and freezers contained undated, unlabeled, expired, or uncovered food items. The walk-in refrigerator had expired cottage cheese, undated produce, dirty shelves and floor, and unidentifiable packages; the cook line refrigerator contained jars without open dates, undated eggs, and unidentified food items. Staff acknowledged the dirty condition of the kitchen, missing thermometers, incomplete logs, and uncovered food on the salad cart. Additional observations included staff with facial hair not wearing beard nets, inconsistent hand hygiene and glove use, and food being handled and plated while staff touched non-food surfaces. Facility policies required food to be stored, prepared, served, transported, and distributed with protection from contamination, required proper labeling and dating, and required temperature monitoring and safe food handling, but the observed practices did not match those requirements.
Improper Disposal of Room Trays, Food Waste, and Garbage
Penalty
Summary
The facility failed to properly dispose of room trays with leftover food and beverages in a timely manner and failed to dispose of garbage and waste properly. On 1/21/2026, a cart with room trays, plates, and cups was observed outside room GP10 before breakfast had been served. Later that morning, three meal trays were observed in a cubie across from the Clinical Office containing uncovered food items, including vegetable soup, brown liquid, uncovered ice cream cups, sloppy joe sandwiches from the prior day’s lunch, carrots, green beans, an opened fruit cup, and silverware. The trays remained there for hours and were later moved to a cart placed in front of the nurse’s station by the LTC entrance before being removed from the hall. On 1/22/2026, a cart of trays was observed outside the kitchen with plates of chicken alfredo from the prior day’s lunch, a hot dog, apple core, unidentified food items, cups, silverware, condiments, food wrappers, and clothing protectors. The cart remained in the hall for over an hour before being removed. On 1/29/2026, another cart with multiple room trays and uncovered food on all three shelves was observed in the hall behind the nurse’s station, along with a red cooler, ice scoop, blue latex gloves, medication cups, cups with fluid, silverware, and a meal ticket for Resident #3’s lunch from the prior day. That cart also remained in the hall for a period of time before being removed. Kitchen observations on 1/20/2026 showed the walk-in refrigerator contained expired cottage cheese, undated fresh produce, no internal thermometer, an unidentifiable package, and dirty shelves and floor. Dirty dishes from the previous day’s meals were on the counter next to the dish machine, and items removed from the refrigerator were placed on top of and beside an overflowing garbage can without a lid located near the door used to transport food out of the kitchen. Staff interviews indicated trays should be picked up within about an hour or two after meals, not left until the next day, and that trays left in halls or in front of sleeping residents were not acceptable. The DON stated CNAs were responsible for removing room trays and that trays should not be left in the halls with the previous day’s food on them.
Incomplete Records, False Documentation, and Unsecured Resident Information
Penalty
Summary
The facility failed to maintain complete and accurate resident records and safeguard resident-identifiable information. Clinical record review, staff interviews, and observation showed that inventory lists for personal property were not completed for residents who reported missing belongings, including missing pants, shirts, and reading glasses. The DON acknowledged that a personal property list was expected on admission and updated when items were brought in, but the records reviewed did not contain those lists. The facility also failed to accurately document medication administration and treatments. For one resident with moderate cognitive impairment and multiple stage 4 pressure ulcers, the MAR showed repeated oxycodone administration by one RN, while the resident stated she had not requested PRN pain medication and did not feel staff gave it unless she asked. The DON stated there were concerns about false documentation and misappropriation of medications. For another resident with intact cognition who had a feeding tube, an RN initialed the MAR for a tube flush before the flush was completed, and the DON stated staff should not sign off medications or treatments prior to completion. Additional record review showed documentation of treatments and pain medications signed out at times when staff were not present or had not retrieved the medication. The facility failed to protect confidential health information and to accurately document kitchen temperature and cleaning logs. During treatment observation, an RN left a laptop partially open and unlocked while viewing a resident’s EMR, allowing access to resident information. In the kitchen, multiple refrigerator and freezer temperature logs and cleaning logs had missing entries, and later the missing temperatures were filled in with the same initials. Staff stated they could recall the missing temperatures, but the records showed numerous gaps across several logs. The facility’s own policies required accurate documentation, monitoring of food temperatures, and investigation of grievances and complaints, but the report also noted incomplete grievance handling related to missing resident property.
Infection Control Failures During Resident Care and Equipment Handling
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program as evidenced by multiple observed breaks in infection control practices during resident care. During wound care for a resident with intact cognition and active skin treatments, staff completed portions of care without hand hygiene between glove changes and between moving from one body site to another, and the resident’s heel wound was treated while the staff continued care without sanitizing hands as required by the facility’s hand hygiene policy. The observation also showed staff handling the resident’s gown and bedding during the treatment process before completing hand hygiene at the end. For another resident with severe cognitive impairment and an indwelling catheter, a CNA exited the resident’s room and walked down the hallway while still wearing a gown and gloves after emptying the catheter. In a separate wound treatment for a resident with severe cognitive impairment and an unstageable pressure injury, one staff member donned gloves without hand hygiene, and during the dressing change the nurse did not change gloves or perform hand hygiene between removing the old dressing and applying the new dressing. After the treatment, staff left the room and walked down the hall before completing hand hygiene. Additional observations showed infection control lapses during catheter care, transfer assistance, and equipment handling. For one resident with intact cognition and a long-term urinary catheter, staff performed peri care and catheter care without changing gloves or sanitizing hands between tasks, placed the catheter drainage bag back into the recliner pocket, and moved a mechanical lift from the room into the hallway without wiping it down. For another resident dependent on a mechanical lift and on enhanced barrier precautions due to a catheter and open wounds, staff completed the transfer and then placed the lift in the hallway without sanitizing it. For a resident using oxygen, the nasal cannula was not in place, the oxygen tubing was lying on the floor, and the concentrator tubing end was on the floor when staff reconnected it. The facility also had an undated infection prevention and control policy that had not been reviewed annually, and the infection preventionist stated the program had not been reviewed annually and that the facility was not tracking infections, infection rates, or antibiotic use.
Failure to Assess and Treat Diabetic Ulcer and Head Injury for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate assessment and treatment for a diabetic foot ulcer for one resident and failure to appropriately assess and monitor a head injury for another resident. For the first resident, the admission/readmission progress note dated 1/5/26 documented no impaired skin integrity, including no diabetic ulcer or open areas, despite the resident later being identified as having a diabetic ulcer on the second digit of the left foot. The resident, who had a BIMS score of 15 indicating no cognitive impairment, reported that she had informed the RN/ADON about the sore on her foot and that nothing was done until another RN intervened. The electronic health record showed that a wound evaluation entered on 1/15/26 documented a diabetic ulcer on the left second toe, present on admission, with specific measurements and description, and physician notification at that time. Further review of the records for this resident showed that the wound was again evaluated on 1/16/26 and 1/23/26 with documented measurements, but there was no documentation of any physician notification or treatment for the wound from the time of admission on 1/5/26 until 1/15/26, when the RN first addressed the area. A physician’s order to cleanse the second toe on the left foot and apply triple antibiotic ointment with a bandage daily had a start date of 1/15/26, indicating that treatment was not initiated until ten days after admission. The DON stated that the initial admission skin assessment was completed by one RN who left without documenting the assessment, and that the evening nurse then completed the assessment again. The DON also stated she did not think the initial nurse observed the resident’s foot or toe, acknowledged that the wound should have been noticed on admission, and confirmed that the resident was in the facility for a week without the wound being assessed or treated. For the second resident, who had a BIMS score of 13 indicating no cognitive impairment, the facility failed to appropriately assess and monitor a head injury and associated bruising. A skin check dated 12/22/25 documented no skin issues. On 1/4/26 in the morning, an LPN observed a scratch or red mark on the right side of the resident’s forehead and obtained an initial set of vital signs and an assessment as part of the daily assessment, but did not initiate neuro checks at that time and did not remove the resident’s clothing to assess hips or buttocks, only pulling pant legs up. The LPN reported conflicting accounts from the resident about how the injury occurred and stated she was not aware of any procedure for injury of unknown origin or for witnessed/unwitnessed head injury. Later that day, when the resident’s daughter arrived, the area on the forehead had progressed to a swollen “goose egg,” at which point neuro checks were started and the on-call provider was notified, with documentation showing neurological assessments beginning at 6:00 PM and a skilled note at 7:49 PM describing a hematoma to the right forehead and notifications made. The resident’s daughter reported finding her mother with a bruise on the knee and a wound on the right side of the head, and stated the resident told her she had fallen in the bathroom that morning. She also reported that additional large bruises on the right hip and right shoulder blade were only discovered and brought to attention when the resident was examined in the emergency department the following day. The DON acknowledged that there had been an injury of unknown origin and that staff had not notified the physician or family appropriately when the injury was first found in the morning, and that neuro assessments should have been initiated at that time but were not. The DON stated she would have expected staff to notify her, the physician, and the family when the head injury was first observed at approximately 7:30 AM, and confirmed that these actions were not completed as expected. The nurse practitioner stated she was notified of the forehead area and conflicting stories but was not made aware of the goose egg or any other bruising, and that she would have expected staff to call with any head injuries and start neuro assessments immediately.
Failure to Provide SNF ABN With NOMNC
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN), Form CMS-10055, for 3 of 3 residents reviewed: Resident #50, Resident #51, and Resident #52. For each resident, a Notice of Medicare Non-Coverage (NOMNC) was signed indicating that Medicare coverage of skilled nursing services would end on a specified date, but the SNF ABN was not provided for the resident to complete. The facility also used an outdated NOMNC form, Form CMS 10123-NOMNC approved 12/31/11, instead of the current CMS NOMNC Form CMS-10124-DENC expiration 11/30/27. Staff N, Interim Director of Social Services, stated she had been trained by the previous Director of Social Services that the SNF ABN was only completed if a resident chose to remain in the facility or was on Medicare Part B services. She acknowledged knowing what the SNF ABN CMS Form-10055 was and having access to it, but said she did not know the NOMNC form had been updated and had been using a form from the previous director with the heading changed to the current facility name. The Administrator stated he was not aware the SNF ABN form was not being utilized with the NOMNC and was not aware the facility was not using the current NOMNC form.
Residents’ PRN opioid medications were improperly signed out and administered
Penalty
Summary
The facility failed to protect residents from the wrongful use of their belongings or money by allowing a staff member to repeatedly sign out and administer PRN opioid pain medications to residents without the residents requesting them and, in one case, with a discrepancy in controlled substance counts. The deficiency involved Resident #3, Resident #11, and Resident #32, all of whom had pain-related diagnoses and PRN narcotic orders. The report states that Staff A routinely gave oxycodone to Resident #3 and hydrocodone-acetaminophen to Resident #11, and Staff A acknowledged that she gave pain medications prophylactically, even if the residents did not ask for them. Resident #3 had a BIMS score of 11 and diagnoses including stage 4 pressure ulcers, renal failure, and stroke. Her MAR showed multiple oxycodone administrations signed out by Staff A, including on days when Staff A’s timecard showed she was on lunch break at the time the medication was documented as given. On interview, Resident #3 stated she had not requested a PRN pain medication for a long time, that staff would ask if she wanted one but she would say no, and that she would know if she had been given extra medication. Staff A later stated she had been routinely giving Resident #3 oxycodone and would give it without asking. Resident #11 had a BIMS score of 15 and diagnoses including right femur fracture and prostate cancer. His MAR showed repeated hydrocodone-acetaminophen administrations signed out by Staff A. During interview, Resident #11 stated he had pain all the time, that he usually asked for Tylenol first, and that since the hydrocodone order was started he had asked for it once but never received it. He denied seeing Staff A bring the medication to him. Staff A stated she had given him hydrocodone when he asked, but the resident’s account did not match the documentation. Resident #32 had a BIMS score of 12 and diagnoses including acute respiratory failure with hypoxia, atrial fibrillation, heart failure, and renal failure. Her care plan did not address pain management. Her MAR showed hydromorphone ordered PRN for pain/shortness of breath and signed out by Staff A. The controlled drug record showed 3 mL missing from the bottle when the DON and ADON counted it, and Staff A was the only person documented as signing out the medication. The facility policy stated residents have the right to be free from exploitation and misappropriation of property by staff, but the events described showed repeated PRN narcotic use and controlled substance discrepancies involving these residents.
Failure to Obtain Bed Hold Notifications
Penalty
Summary
The facility failed to obtain bed hold notifications for 2 of 3 residents reviewed, Resident #5 and Resident #29. For Resident #5, the record showed he was discharged to a short-term general hospital on 8/13/2025 after becoming hypotensive, weak, dizzy, and nauseated while being assisted to a recliner for therapy, and later that day was admitted to the hospital due to declining renal function. The record did not contain a completed bed hold form from Resident #5 or his representative, and the Administrator acknowledged by email that the facility was unable to locate the form when he was sent to the hospital. For Resident #29, the record showed the resident had a BIMS score of 15 and left the facility by transport to the hospital ED for elevated pulse, increased pain, and nausea, with documentation stating that the bed hold policy was given to the resident. The resident returned to the facility on 1/12/26, but the facility later confirmed by email that no bed hold form had been completed for the hospitalization. The facility policy stated that residents and/or representatives are to be informed in writing of bed-hold policies, including notice in advance of transfer and again at the time of transfer or within 24 hours if the transfer is an emergency.
Inaccurate MDS Coding for Assessment Type and Antipsychotic Use
Penalty
Summary
The facility failed to accurately code the type of assessment for Resident #5 on the discharge Minimum Data Set (MDS). The resident’s MDS Entry assessment documented that it was not the first assessment since the most recent reentry to the facility, while the MDS admission assessment documented that it was the first assessment since the most recent reentry. The MDS discharge assessment also documented that it was not the first assessment since the most recent reentry. Review of the resident’s EHR Census tab showed a discharge return not anticipated MDS completed on 2/2/2024 and an entry MDS completed on 8/7/2025. The DON stated the MDS Coordinator was responsible for overseeing MDS assessments for accuracy, and the MDS Coordinator stated the issue sounded like a census issue with the BOM. The facility also failed to accurately code whether residents were taking antipsychotic medications for 2 of 3 residents reviewed, Resident #5 and Resident #23. For Resident #23, a physician order dated 2/7/25 showed Rexulti, an atypical antipsychotic used to treat symptoms associated with agitation from dementia. The resident’s MDS assessments dated 2/11/25, 5/9/25, 8/1/25, and 10/24/25 documented a diagnosis of Alzheimer’s dementia but inaccurately indicated the resident did not take an antipsychotic medication. The care plan, last revised 1/8/26, identified use of antipsychotic/psychotropic medications related to behavior management. The MDS Coordinator stated she completed MDS assessments for all residents, reviewed physician orders and the MAR to determine antipsychotic use, and was unsure how she missed identifying the medication.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a Baseline Care Plan within 48 hours of admission for 2 of 10 residents reviewed. For Resident #17, the MDS showed a BIMS score of 12/15 with moderate cognitive impairment and diagnoses including atrial fibrillation, heart failure, non-Alzheimer's dementia, and COPD, with oxygen use while a resident. Although the EMR contained care plan focus areas for oxygen therapy and impaired cognitive function, the record did not contain documentation in the progress notes showing that a Baseline Care Plan had been completed or that the resident or representative had been involved in its development. The EMR also did not contain a Baseline Care Plan signed by the resident or representative. Resident #17 stated she did not know what a Care Plan Conference was or remember talking with staff in a meeting about her care plan. Staff N, Interim Director of Social Services, stated the Baseline Care Plan Conference had not been held until 1/28/26, and that it was done on short notice without additional IDT members present. Staff N stated she contacted therapy and nursing for input before the conference and that the daughter was contacted by phone for input and provided a copy of the document with verbal consent by the resident's representative. For Resident #42, the MDS showed a BIMS score of 12/15 and diagnoses including UTI in the past 30 days, diabetes mellitus, history of falling, fainting and collapse, and a personal history of strokes without residual deficits. The care plan included needs for assistance with ADLs, therapy services, and discharge planning, but the EMR progress notes did not show a Baseline Care Plan Conference or that the Baseline Care Plan was provided to the family or representative. The EMR Baseline Care Plan had no resident or representative signature and was electronically signed/closed on 1/15/27. Resident #42 stated she did not know anything related to a Care Plan or Care Plan Conference, and Staff N stated the Baseline Care Conference had not yet been held because she had been out with the flu and had not scheduled it, acknowledging a lapse in judgment.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities that incorporated Resident #21’s interests and hobbies to support physical, mental, psychosocial well-being, and independence. Resident #21 had a BIMS score of 8/15 indicating moderate cognitive impairment, was incontinent of bowel and bladder, dependent for bed mobility and transfers, and had diagnoses including heart failure, A-fib, and impaired brain function. Her care plan addressed impaired cognitive function and short-term memory loss with interventions such as medications as ordered, yes/no questions, cueing, re-orientation, and supervision, but it did not identify person-centered activities for her. Observations showed Resident #21 repeatedly seated in her wheelchair in the day room or living room with no activity or stimulus, including being positioned at a table facing a blank TV screen and wall. She was observed multiple times without engagement, including while sleeping at the table and later awake with no activities present. Staff were observed attempting to turn on the TV without success and then leaving the room without providing another activity. Staff later stated there were activities available such as the TV, coloring books, and an activity board, but the TV had not worked for several days and maintenance had not been notified by the CNA. The DON stated residents seated in the living room should always be provided with activities and that it was not acceptable for them to be positioned without engagement; the Administrator stated residents should not be sitting without activities or something to engage with, and also stated the facility did not have a policy related to activities for residents.
Improper Enteral Tube Flush Administration
Penalty
Summary
The facility failed to implement policies and procedures regarding the technical aspect of feeding tubes for 1 of 1 residents with an enteral tube, Resident #44. Resident #44 was admitted from another nursing home on 1/15/2026, had a BIMS score of 14 indicating intact cognition, and had an order to flush the feeding tube with 25 milliliters of water twice daily. During observation on 1/21/2026 at 10:45 AM, Staff A RN performed hand hygiene, donned gown, gloves, and goggles, checked tube placement, and then pushed 25 cc of water into the resident’s enteral tube rather than allowing the flush to flow by gravity. In interviews, the DON stated that staff should not be pushing medications or flushes through enteral tubes and that flushes and medications should be passed using gravity, and further stated that the facility policy for enteral nutrition did not include information about allowing medications or water flushes to flow by gravity, although she expected flushes to be completed via gravity as standard practice.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for a resident who required oxygen. The resident had a BIMS score of 12/15 and diagnoses including A-fib, heart failure, non-Alzheimer's dementia, and COPD. The care plan addressed oxygen therapy and the physician order specified oxygen at 2 L/minute, but the resident was observed on 1/20/26 seated in a recliner with the concentrator turned on at 4 L/minute, the nasal cannula not in place, and the tubing lying on the floor disconnected from the concentrator. The resident stated she was having a hard time catching her breath and said the oxygen had been a mess since admission. On 1/21/26, the resident was observed in a wheelchair with an E-Tank on the back of the chair, the nasal cannula in place, and the tank regulator dial appearing in the red, indicating the tank was either not turned on or out of oxygen. Staff stated the oxygen was not turned on and the regulator needed to be reset. Later that morning, the resident stated she felt better after her oxygen was turned on and said it was an ongoing issue when moving between the concentrator and E-Tank. On 1/26/26, the DON observed the oxygen turned on with the E-Tank almost empty and noted the regulator was set at 0.5 L/minute instead of the ordered 2 L/minute. The DON acknowledged concerns that the resident's oxygen was not being managed correctly per physician orders.
Failure to Serve Ordered Diet Consistencies
Penalty
Summary
The facility failed to prepare and serve food in a form designed to meet individual needs and according to resident assessments and care plans for 3 of 5 residents reviewed. Resident #3 had moderate cognitive impairment, a care plan identifying a mechanical soft diet with increased protein due to difficulty chewing, and a physician order for a regular diet with mechanical soft texture and thin liquids. Resident #13 had severe cognitive impairment, a care plan addressing nutritional problems related to vitamin B deficiency and dysphagia with an intervention for a mechanical soft diet, and a physician order for a mechanical soft diet with regular texture and thin liquids. Resident #23 had severe cognitive impairment, a care plan addressing nutritional problems related to diabetes mellitus and dementia with an intervention to provide and serve the diet as ordered, and a physician order for a consistent carbohydrate diet with mechanical soft texture and thin liquids. During continuous observation of the noon meal service, staff prepared and plated meals without using meal tickets or resident menus. A dietary aide notified the cook/dietary manager that 3 mechanical soft plates were needed, and the cook modified only part of the egg noodles by pushing aside regular noodles and altering a portion of them with a scraper/chopper. The staff then plated semi-modified egg noodles, regular chicken, and vegetables, covered the plates, and placed them on the warming shelf before sending them to the dining room. The dietary aide could not identify the mechanical soft plates from the regular plates for distribution to residents. The facility also removed a fruit crumble tray from the cooler and placed it uncovered on the delivery cart, with all pieces precut but without differentiation for diet consistencies or therapeutic diets. The menu spreadsheet for the meal showed that residents on mechanical soft diets were to receive ground chicken over chopped egg noodles, soft chopped fruit crumble, and a soft dinner roll, but the facility did not modify the egg noodles, chicken, or fruit crumble as ordered and did not provide the soft dinner roll. Staff interviews confirmed that diets were to be prepared according to physician orders and approved menus, that foods for specific consistencies must be altered appropriately, and that meal tickets were needed to ensure orders were followed.
Therapeutic Diet Orders Not Followed
Penalty
Summary
Therapeutic diets were not provided as ordered for 3 of 6 residents reviewed, involving consistent carbohydrate and renal diets. Resident #23 had diagnoses including diabetes mellitus, high cholesterol, and Alzheimer's disease, and the clinical record showed an order for a consistent carbohydrate diet with mechanical soft texture and thin liquids. The resident's care plan included interventions to maintain the ordered diet and to provide the diet as ordered. Resident #33 had diagnoses including heart failure, renal insufficiency, diabetes mellitus, Parkinson's disease, and a traumatic great toe amputation, and the record showed an order for a renal diet with regular texture and thin liquids. The family stated the resident did not consistently receive breakfast before leaving for dialysis, was given a shake that was not acceptable as a pre-dialysis meal, did not receive a brown bag meal substitution, and sometimes received cereal that was not part of the renal diet. The family also stated menus were not consistently provided, approved alternatives were not consistently offered, and selected menu items that were part of the diet were not consistently received. Resident #42 had a BIMS score of 12/15 and required a therapeutic diet for diabetes mellitus, with an order for a consistent carbohydrate diet. During lunch meal service, staff did not consistently use meal tickets when preparing and serving meals in the dining room and room trays, and the dietary staff stated they did not know who had what orders or had been served. The meal served did not match the prescribed menu portions for the renal and consistent carbohydrate diets, including missing the dinner roll and providing portions of chicken, noodles, and dessert that were not consistent with the approved menu. The registered dietitian stated cooks were to follow the menus and contact her for substitutions, and that therapeutic diets must be followed.
Failure to Follow Physician Orders and Notify Providers Regarding Medication Administration
Penalty
Summary
The facility failed to provide needed services in accordance with professional standards by not following physician orders for multiple residents. For one resident with severe cognitive impairment and multiple diagnoses, including atrial fibrillation, heart failure, and respiratory failure, the facility did not administer three prescribed medications, failed to obtain daily weights as ordered, and administered a medication despite the resident's pulse being below the prescribed parameter. Documentation was missing for several medication administrations and required monitoring. Another resident with severe cognitive impairment and multiple chronic conditions, including coronary artery disease, hypertension, and neurogenic bladder, experienced repeated refusals of several scheduled medications and supplements over multiple days. The facility did not notify the primary care provider of these refusals, both for single instances and for continuous refusals over three days, despite facility policy requiring such notification. The resident subsequently refused all medications, nutrition, and hydration for a period, and was later taken to the hospital by family with a diagnosis of complicated urinary tract infection and altered mental status. Staff interviews confirmed that the primary care provider was not notified as required. A third resident with normal cognition and diagnoses including anemia, atrial fibrillation, and renal insufficiency received medication outside of prescribed parameters, specifically antihypertensive medication when blood pressure or pulse was below the hold parameters. There was also a lack of documentation for vital signs required before administration of these medications, and medications were held without physician orders when no parameters were specified. Staff and administration interviews confirmed that documentation was lacking and that medications were administered or withheld outside of physician orders and facility policy.
Failure to Provide and Document Catheter Care and UTI Monitoring
Penalty
Summary
The facility failed to provide catheter care and monitoring in accordance with professional standards for three residents with indwelling catheters. For each resident, there were multiple instances where catheter output was not documented as required by physician orders and facility policy. In addition, the facility did not consistently monitor or report changes in eating patterns, which were identified in care plans as potential signs or symptoms of urinary tract infection (UTI). One resident with severe cognitive impairment and a history of atrial fibrillation, heart failure, and recent UTI had an indwelling catheter. The resident's treatment records showed missing documentation of catheter output on several shifts, and there was no evidence that changes in eating patterns were reported as required. The resident was hospitalized with severe sepsis due to UTI, with hospital records noting overt purulence in the catheter and abnormal urinalysis results. Another resident with neurogenic bladder and a suprapubic catheter also had multiple missed entries for catheter output and decreased nutritional and fluid intake that was not reported to the primary care physician. This resident was subsequently hospitalized for a complicated UTI, and the physician confirmed that notification should have occurred for decreased intake. A third resident with normal cognition and a history of anemia, renal insufficiency, and recent UTI also had an indwelling catheter. Documentation of catheter output was missing for several shifts across multiple months, and there was no supporting documentation in the medical record for these omissions. Interviews with nursing staff and facility leadership confirmed that lack of documentation indicated the task was not completed, and that the expectation was for catheter output to be recorded each shift as ordered. Facility policy required catheter bags to be emptied and output documented at least every eight hours, with unusual findings reported to the physician.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Surveyors identified that the facility failed to implement appropriate infection prevention and control practices, specifically regarding hand hygiene and the use of Enhanced Barrier Precautions (EBP) during resident care for two out of three residents reviewed. Observations and record reviews revealed that staff did not consistently follow EBP protocols, such as wearing gowns and gloves during high-contact care activities, and did not always perform hand hygiene at required times, including between glove changes. The facility's own policies and posted signage required these precautions for residents with indwelling catheters, wounds, or pressure ulcers, but these were not always adhered to during care activities such as transferring, grooming, and catheter care. One resident with severe cognitive impairment, a suprapubic catheter, and a history of urinary tract infection was observed receiving care where staff initially followed infection control practices but failed to don gowns during subsequent high-contact activities like transferring and grooming. Another resident with an indwelling catheter, pressure ulcer, and multiple comorbidities was observed during care where staff changed gloves without performing hand hygiene, contrary to facility policy and CDC guidelines. Documentation also showed lapses in recording EBP implementation for this resident during certain shifts. Interviews with the Interim Director of Nursing and the Administrator confirmed that staff were expected to follow EBP protocols, including the use of gowns and gloves for high-contact care and hand hygiene between glove changes. However, direct observations and record reviews demonstrated that these expectations were not consistently met, resulting in a failure to fully implement the facility's infection prevention and control program as required.
Failure to Implement and Document Fall Prevention and Post-Fall Assessments
Penalty
Summary
The facility failed to provide appropriate interventions to prevent falls and did not complete required neurological assessments after unwitnessed falls for several residents. For one resident with severe cognitive impairment and a history of falls, the care plan was not updated with new interventions after multiple falls occurred on consecutive days. Progress notes documented repeated incidents of the resident being found on the floor, but no additional fall prevention strategies were added to the care plan following these events. Another resident experienced multiple unwitnessed falls, but the neurological assessment flow sheets showed that vital signs, level of consciousness, pupil response, motor functions, and pain response were not consistently documented as assessed after these incidents. This lack of documentation was also observed for another resident with severe cognitive impairment and a history of falls, where neurological checks were incomplete or missing after unwitnessed falls, despite facility policy requiring such assessments for a 72-hour period following an unwitnessed fall. Additionally, a resident with mild cognitive impairment and multiple medical diagnoses, including a history of falls, was observed with fall prevention equipment not consistently in use, such as a fall mat being folded and not placed by the bed. The care plan for this resident included general fall prevention measures, but after documented falls, there was no evidence of individualized interventions being added. Staff interviews revealed inconsistent knowledge and use of care plans and interventions, and the facility was unable to provide a current policy regarding fall interventions after a fall, relying instead on an outdated neurological assessment policy.
Failure to Update Facility Assessment Following Change in Ownership
Penalty
Summary
The facility failed to update its Facility Assessment to reflect current operations and resources necessary to care for its 26 residents. The most recent Facility Assessment provided was dated from July 2023 through June 2024 and still referenced the previous facility name, despite a change in ownership in February. The current CEO, acting as Administrator, confirmed that the assessment had not been updated since the new management took over. The Skilled Unit Manager/ADON reported being unable to access the previous owners' program to obtain policies and could not locate a relevant policy in the facility's binders. Additionally, corporate staff were asked to provide the policies they intended to implement, but as of several days after the request, no policies had been provided.
Failure to Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified individual to serve as the Infection Preventionist (IP) responsible for the infection prevention and control program. According to document reviews and staff interviews, the designated IP, who is also the MDS Coordinator, had not completed the required specialized training in infection prevention and control, having only started the modules in April. The Director of Nursing (DON) was also undergoing the same training, and both relied on a corporate nurse for assistance, who was not regularly present at the facility. The facility's policy required the IP to be adequately qualified and to have completed accredited continuing education, which had not occurred at the time of the survey. Further review revealed that the antibiotic stewardship program, which falls under the IP's responsibilities, was not up to date, as evidenced by an incomplete binder for the current year. Staff interviews confirmed uncertainty regarding the IP's prior training and the lack of completion of required documentation. Additionally, the facility was unable to provide updated policies from the new ownership when requested by surveyors, indicating a lack of clear guidance and oversight for the infection prevention and control program.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and homelike environment for its residents. Over several days, multiple dead June bugs were seen on the floor between exit doors near a resident room, and these were not removed despite repeated observations. Additionally, a family member reported that housekeeping had not cleaned her relative's room since admission, leading her to personally pick up debris from the floor and bathroom. Direct observations confirmed the presence of white debris by the resident's recliner, a white spot under chairs, and a brown stain running from the toilet bowl to its base in the bathroom. These conditions persisted over multiple days, even after the concerns were brought to the attention of facility leadership. Interviews with staff revealed that housekeeping is expected to clean resident rooms and bathrooms daily, typically with two housekeepers on duty, though sometimes only one is available. Despite these expectations, the staff member interviewed denied receiving any complaints from residents about cleanliness. The ongoing presence of debris and unsanitary conditions in the resident's room and bathroom, as well as the accumulation of dead insects in common areas, demonstrate a failure to provide a clean and safe environment as required.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 359 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Council Bluffs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Gate | 1.6 mi | ★★★★★ | 3 | 0 |
| Prairie Gate | 2 mi | — | 0 | 0 |
| Prairie Gate | 2 mi | — | 0 | 0 |
| Bethany Lutheran Home | 2.4 mi | ★★★★★ | 13 | 1 |
| North Crest Living Center | 3.2 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.