Country Lane Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Keosauqua, Iowa.
- Location
- 819 Country Lane Road, Keosauqua, Iowa 52565
- CMS Provider Number
- 165204
- Inspections on file
- 25
- Latest survey
- August 12, 2025
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Country Lane Manor during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage, sanitation, and handling, including uncovered food in storage, expired milk and cheese in the refrigerator, and a microwave with dried residue. Staff were observed placing used spatulas directly on countertops during meal preparation, and interviews revealed inconsistent practices for checking expired food and cleaning kitchen equipment.
The facility experienced repeat deficiencies in bowel/bladder care, kitchen sanitation, and QAPI program implementation due to an ineffective QAPI process. Despite monthly Quality Assurance Committee meetings and a policy outlining data-driven improvement activities, the same issues were cited in consecutive recertification surveys.
A resident with moderate cognitive impairment and intellectual disability, who was frequently disoriented and unable to make complex decisions, did not have a designated representative for medical or financial decisions. Staff and administration confirmed that no attempts were made to identify or assign a POA, conservator, or guardian, despite facility policy and care plan directives requiring such action.
A resident with diabetes, paraplegia, and spina bifida was allowed to self-administer insulin without a documented assessment of safety or competency, as required by facility policy. The resident independently injected insulin under RN supervision, but the care plan and medical record lacked evidence of an interdisciplinary team assessment or documentation supporting the decision to permit self-administration.
The facility did not adequately promote or facilitate resident choice, resulting in a failure to support a resident's right to self-determination as required by regulation.
Staff did not promptly inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident with BPH, a recent UTI, and overflow incontinence was admitted with an indwelling urinary catheter, as documented in the MDS and physician orders. However, the care plan did not address the catheter or provide interventions for its care, despite facility policy requiring comprehensive care plans for all resident needs.
A resident with an indwelling urinary catheter and recent UTI did not have clear physician orders specifying catheter size, type, or change frequency, and the care plan lacked interventions for catheter care. Staff delayed obtaining a urinalysis due to miscommunication, and observations noted cloudy urine and resident discomfort. Interviews revealed confusion among staff about catheter care protocols and a lack of documentation consistent with facility policy.
The facility did not ensure that its QAPI group included all required members at quarterly meetings, as attendance records showed the Medical Director was present at only one meeting and the policy did not specify required attendees. The Administrator could not provide documentation to confirm additional attendance.
Staff failed to consistently follow infection prevention protocols for two residents with indwelling urinary devices. In one case, appropriate PPE was not used during urostomy care, and the care plan lacked direction for Enhanced Barrier Precautions. In another case, a nurse did not change gloves between cleansing a suprapubic catheter site and applying a new dressing. Facility policies did not adequately address these infection control procedures.
A resident with severe cognitive impairment and dementia experienced a delay in treatment for an eye infection when initial symptoms were reported to an LPN, but no timely provider response or intervention occurred. Only after a subsequent family complaint did an RN assess the resident and obtain an order for antibiotic eye drops, resulting in a delay in care.
The facility failed to serve food in an attractive and palatable manner during meal services. A resident reported that a chicken patty was hard and difficult to cut, while another resident found the mixed vegetables bland and the meal overly carbohydrate-heavy. Both residents had intact cognitive status and significant medical histories.
A resident with a history of necrotizing fasciitis and pressure ulcers did not receive the prescribed wound dressing changes due to a failure in implementing physician orders. Despite documented orders, staff were unaware or unclear about the new dressing orders, leading to a lack of action. The facility's process for handling treatment orders was not followed, resulting in the deficiency.
The facility failed to maintain consistent procedures for advance directives for six residents. Observations revealed incorrect or missing Full Code magnets on doors, and staff were often unaware of the correct code status. The administrator acknowledged the issues and considered removing the magnets due to their inaccuracy and potential for being moved by residents.
The facility did not perform Monthly Drug Regimen Reviews for July, affecting all 56 residents. The Administrator confirmed the absence of reviews and presented an email from a Consultant Pharmacist, who noted that recommendations from July were not completed and re-issued relevant ones. Facility policy requires monthly comprehensive medication regimen reviews, which were not conducted.
The facility failed to provide adequate nursing staff, impacting the admission process and resident care. Interviews revealed that only one nurse per shift often leads to incomplete admissions, with the absence of an ADON exacerbating the issue. The DON expressed concerns about minimal staffing levels, resulting in administrative staff covering nursing duties, leading to burnout and safety concerns. The CMS PBJ Staffing Data Report confirmed low staffing levels, particularly on weekends, affecting the facility's ability to meet resident needs.
The facility failed to maintain proper food safety and sanitation protocols. A cook did not change gloves appropriately during meal service, risking contamination. A resident food refrigerator lacked a thermometer and contained expired, undated food. The dishwasher log was incomplete, and cups appeared inadequately cleaned, indicating lapses in sanitation practices.
The facility's QAPI process failed to address previously identified deficiencies, resulting in repeated issues in areas such as resident rights, accommodation of needs, professional standards, and more. Despite monthly reviews by the Quality Assurance Committee, the same deficiencies were noted in consecutive surveys over six months.
A facility failed to implement a GDR for a resident's Duloxetine medication despite multiple recommendations from a consultant pharmacist and agreement from the primary provider. The resident continued to receive a 40 mg dose instead of the recommended 30 mg, with the MAR not updated to reflect the change. The resident's family disagreed with the reduction, but there was no prescriber documentation supporting this decision, and the resident had intact cognition.
A resident with intact cognition and a history of anxiety and depression expressed a preference not to be assisted by a specific CNA due to perceived rudeness. Despite assurances from the facility that the CNA would not return, the resident reported continued assistance from the CNA, violating the resident's rights to dignity and self-determination.
A resident with intact cognition but moderate hearing difficulty and limited vision reported being unable to access the bathroom sink with their wheelchair and experienced issues with a malfunctioning over-bed lamp. Despite voicing these concerns, no work orders were submitted, and the facility failed to address the resident's grievances, violating their policy on resident rights.
The facility failed to follow basic nursing principles for two residents, leading to significant deficiencies. A resident was readmitted without notifying the primary provider, resulting in missed medications. Another resident, under hospice care, was given morphine from another resident's bottle due to a lack of proper medication supply. Staff acknowledged these errors, highlighting issues in communication and medication management.
A facility failed to follow Provider's orders for a resident's indwelling catheter balloon size, leading to the use of an incorrect 30 mL balloon instead of the prescribed 10 mL. This error was discovered after the resident reported bladder pain and catheter malfunction. The facility's catheter care policy required staff to review care plans for special needs, which was not adhered to.
A facility failed to resubmit a PASRR level 2 approval within the appropriate time frame for a resident with Bipolar Disorder, Schizophrenia, and Dependent Personality Disorder. The resident required staff assistance and had a goal for community discharge. The care plan tasked the Director of Social Services with coordinating services before the PASRR expiration, but the approval expired without timely resubmission. The Facility Administrator acknowledged the lapse and planned an immediate new submission.
The facility failed to properly assess and intervene for two residents experiencing changes in condition. One resident with diabetes had hypoglycemia, but there was inadequate documentation and monitoring. Another resident experienced prolonged constipation, with the facility failing to follow its bowel management protocol. These deficiencies highlight lapses in documentation and adherence to care protocols.
The facility failed to provide adequate pressure ulcer care and monitoring for two residents, resulting in the development and worsening of wounds. Resident #20 developed a deep tissue injury and a stage two pressure ulcer, with inconsistent wound assessments and documentation. Resident #208 was admitted with multiple pressure ulcers that were not thoroughly assessed or consistently monitored. Staff interviews revealed confusion and miscommunication regarding wound care responsibilities, leading to inadequate treatment and documentation.
The facility failed to prevent falls and ensure safety for several residents, leading to multiple injuries. A resident with impaired cognition experienced several falls, including a hip fracture, due to inadequate supervision and lack of timely interventions. Another resident with moderately impaired cognition fell and fractured their hip while self-transferring, despite needing assistance. A resident with intact cognition was pushed in a wheelchair without proper foot pedal use, and another resident with communication difficulties experienced multiple falls due to inadequate preventive measures.
The facility failed to address the nutritional needs and weight loss of several residents, including those with dementia and impaired cognition. Residents experienced significant weight loss, and there was a lack of documentation and communication regarding their nutritional status. Additionally, ordered dietary supplements were often unavailable, contributing to the residents' nutritional deficiencies.
The facility did not ensure consistent access to resident funds outside business hours for five residents using the trust fund. The BOM stated funds were given if requested, but the Administrator admitted that 24-hour access was not consistently available. Facility policy required timely access to funds, which was not upheld.
Inadequate staffing at the facility resulted in several care deficiencies, including a fall with injury for a resident with impaired cognition, delayed toileting assistance leading to incontinence, and missed showers for another resident. Additionally, a resident with severely impaired cognition was observed struggling to eat without assistance. These incidents highlight the facility's failure to respond promptly to call lights and provide necessary care.
The facility failed to provide correct meal portions for residents on mechanical soft and pureed diets. The Dietary Manager did not follow the menu or facility policy, resulting in incorrect servings and missing pureed bread for some residents.
The facility failed to maintain kitchen sanitation and infection control during food service. The dishwashing machine operated below the required temperature, lacked testing strips, and had buildup. The handwashing sink was cold, and there was dust and food debris in the kitchen. The Dietary Manager improperly used gloves, touching various surfaces and serving food without changing them.
A resident with severely impaired cognition was left unassisted during meals, failing to receive timely encouragement or cues. Despite needing setup assistance, the resident struggled with eating, using utensils incorrectly, and was observed with spilled liquid on her lap without staff intervention.
A resident with an acquired absence of the left leg and other health issues was unable to access the sink in their bathroom due to its small size, impacting their independence and well-being. Despite the resident's intact cognition and ability to perform oral hygiene independently, the facility failed to address the issue after it was raised in a care conference. The ADON was unaware of the problem, and the facility's policy on accommodating needs was not followed.
A cognitively intact resident did not receive meal options or a menu, despite being on a regular diet, due to miscommunication and oversight by the facility staff. The resident expressed dissatisfaction, and staff interviews revealed that the Dietary Manager and ADON were unaware of the oversight, failing to uphold the resident's right to self-determination.
A facility failed to notify a resident of the termination of their Medicare Part A coverage. The issue was discovered through a review of clinical records, staff interviews, and policy reviews. The Assistant Director of Nursing acknowledged the absence of a discharge notice for the resident, who was discharged from Medicare Part A. The facility's policy requires notification of service termination and the right to appeal, but this was not adhered to.
The facility failed to complete a background check for an RN before her hire date and did not ensure a CNA had current mandatory reporter training. The Administrator acknowledged the expectations for these requirements, which are outlined in the facility's abuse policy.
The facility failed to ensure accurate MDS coding for several residents, leading to discrepancies in medication and treatment documentation. A resident's MDS indicated anticoagulant use without corresponding MAR documentation, while another resident's MDS failed to document a Foley catheter despite hospice records confirming its presence. Additionally, a resident's MDS did not reflect the administration of an antidepressant, despite daily administration documented in the MAR.
The facility failed to administer medications per physician orders for three residents. A resident with diabetes received insulin without clear parameters for holding doses, leading to inconsistent practices. Another resident missed doses of an anticonvulsant due to unavailability, and a third resident did not follow proper inhaler use instructions, with medication orders lacking dosages. Staff interviews revealed gaps in medication management and adherence to professional standards.
The facility failed to provide consistent assistance with ADLs for three residents, leading to deficiencies in care. A resident with quadriplegia was not properly groomed, another with impaired cognition did not receive necessary eating assistance, and a third resident missed scheduled showers. Staff confusion and inconsistent documentation contributed to these issues.
The facility failed to provide proper catheter care and documentation for two residents, leading to deficiencies. A resident with severely impaired cognition had a Foley catheter not documented in the facility's records, while another resident's catheter tubing was observed touching the ground, posing an infection control risk. Interviews confirmed that catheter tubing should not touch the floor, highlighting lapses in care and infection control practices.
A resident with multiple sclerosis and pressure ulcers had two active orders for hydrocodone/acetaminophen, leading to duplicate administration within the same 6-hour period. Staff interviews confirmed awareness of the duplicate orders, which violated the facility's medication administration policy.
The facility failed to implement gradual dose reductions (GDR) for two residents on psychotropic medications. One resident with intact cognition was prescribed Trazadone, and despite a pharmacist's recommendation for a GDR, no reduction was documented. Another resident with severely impaired cognition was prescribed Duloxetine, and although a GDR was agreed upon, it was delayed by two months. The facility's policy requires GDRs unless contraindicated.
Two residents did not receive bedtime snacks as desired, despite the facility's policy to offer them. Staff interviews revealed that snacks were not provided due to being busy and a lack of available snacks following a corporate change. The Dietary Manager noted budget-related issues with snack availability, although improvements were underway.
The facility failed to maintain an effective QAPI process, resulting in repeated deficiencies over 19 months. Citations included dignity, professional standards, and food procurement issues, with harm level citations for accident hazards/supervision. Despite a QAPI plan, the facility did not sustain improvements, leading to repeated citations.
The facility did not have a sufficient surety bond to cover the total amount of personal funds in the resident trust account for five residents. The surety bond amount was $40,000, but the total resident funds exceeded this amount. The facility's policy required a surety bond on the cumulative total of all resident trust fund balances, which was not adhered to.
Deficient Food Storage, Sanitation, and Handling Practices Identified
Penalty
Summary
Surveyors observed multiple failures in safe food storage, preparation, and sanitation practices within the facility's kitchen. During an initial tour, a partially uncovered leftover chocolate cake was found on a cookie tray in the dry goods storage area. In the walk-in refrigerator, a gallon of 2% milk was present with a date that had already passed, and the Dietary Manager initially believed milk was good for three days past the expiration date. An 18-quart container of shredded yellow cheese was also found with a date from nearly a month prior, and the Dietary Manager disposed of it upon discovery. Additionally, the inside of a microwave was noted to have dried tan residue, indicating it had not been properly cleaned. During a subsequent observation of the noon meal process, the microwave still contained dried residue. While preparing pureed and mechanical soft diets, a dietary staff member used different spatulas for each food item but placed them directly on the countertop without a barrier after checking food consistency. Interviews with dietary staff revealed inconsistent practices regarding checking for expired food and cleaning responsibilities. The Dietary Manager later confirmed that milk should be discarded by the expiration date and noted that a significant quantity of milk had to be thrown away due to improper rotation. The night staff was identified as responsible for nightly checks of refrigerated items for outdated food.
Repeat Deficiencies Due to Ineffective QAPI Process
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process, resulting in the recurrence of three specific deficiencies—F690 (Bowel/Bladder, Incontinence, Catheter, UTI), F812 (Food Procurement, Store/Prepare/Serve-Sanitary), and F865 (QAPI Program/Plan, Disclosure/Good Faith Attempt)—that were previously cited during the 2024 recertification survey and cited again in the most recent recertification survey. The facility had a census of 51 residents at the time of the survey. Staff interviews revealed that the Quality Assurance Committee met monthly and selected focus areas based on grievances, resident council feedback, and 5-star report data, but did not prevent the recurrence of these deficiencies. Review of the facility's QAPI policy indicated a commitment to a comprehensive, data-driven program with specific processes for developing performance indicators, data collection, goal setting, and communication of findings. However, despite these outlined procedures, the facility continued to experience repeat deficiencies in the same areas, indicating that the QAPI process as implemented was not effective in preventing the reoccurrence of issues related to bowel/bladder care, kitchen sanitation, and the QAPI program itself.
Failure to Designate Resident Representation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to attempt to designate a representative for a resident with moderate cognitive impairment and intellectual disability, resulting in the absence of a surrogate to make informed medical and financial decisions on the resident's behalf. The resident, who had a BIMS score of 9 indicating moderate cognitive impairment, was diagnosed with mild intellectual disabilities, mood disorder, psychotic disorder, anxiety disorder, and depression. The resident's care plan identified the need to determine if an appropriate family member, friend, or support person could serve as Power of Attorney (POA), conservator, or guardian, and if not, to refer to the Office of Substitute Decision Maker. However, the admission record listed only the resident as a contact, and there was no documentation of attempts to identify or designate a representative. Staff interviews confirmed that the resident was often disoriented, unable to make complex decisions, and required assistance with medical and financial matters. Despite this, the Director of Social Services denied making any attempts to designate a conservator, guardian, or POA, and the facility administrator confirmed there was no record of such efforts. The facility's policy required assessment of decision-making capacity and identification of a primary decision-maker if the resident lacked capacity, but this process was not followed for the resident in question.
Failure to Complete Self-Medication Assessment Prior to Resident Self-Administering Insulin
Penalty
Summary
A deficiency occurred when the facility failed to complete a self-medication assessment for a resident with type 2 diabetes mellitus, paraplegia, and spina bifida, who was observed self-administering insulin. The resident had an intact mental status, as indicated by a BIMS score of 15 out of 15, and was receiving insulin injections daily. During an observation, a registered nurse prepared the resident's insulin pen, and the resident independently cleaned the injection site and administered the insulin, while the nurse supervised and disposed of the needle. Review of the resident's care plan and electronic health records revealed no documentation of a self-medication assessment or identification of the resident's request to self-administer insulin. Staff interviews confirmed that no assessment had been completed prior to the resident self-administering medication, despite facility policy requiring an interdisciplinary team determination and documentation of safety and appropriateness before allowing self-administration. The care plan also lacked interventions addressing the resident's self-administration of insulin.
Failure to Support Resident Self-Determination
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Include Indwelling Catheter in Care Plan
Penalty
Summary
The facility failed to include the use of an indwelling urinary catheter on the care plan for a resident who had a history of benign prostatic hyperplasia (BPH), a recent urinary tract infection (UTI), and overflow incontinence. The resident was admitted with an indwelling catheter, as documented in the admission Minimum Data Set (MDS) and physician orders, which specified the catheter was to be changed every 30 days for BPH and overflow incontinence. Despite these documented needs, the care plan initiated and later revised for the resident did not address the presence of the indwelling catheter or provide any interventions or directions for its care. Observation confirmed the resident had an indwelling catheter in use, with the tubing and drainage bag stored under the wheelchair and urine visible in the tubing. Staff interviews further verified that the resident had the catheter since admission for the stated medical reasons. The facility's own policy requires comprehensive, person-centered care plans that include measurable objectives and services to meet residents' needs, but this was not followed in the case of the resident with the indwelling catheter.
Failure to Clarify Catheter Orders and Timely Follow-Up on Urinalysis
Penalty
Summary
The facility failed to clarify and document appropriate orders for indwelling urinary catheter care and did not follow up on a urinalysis order in a timely manner for a resident with a history of benign prostatic hyperplasia, recent urinary tract infection, and overflow incontinence. The resident required an indwelling urinary catheter and was always incontinent of bowel. Upon review, the care plan did not identify the need for an indwelling catheter or provide interventions for catheter care, and the physician's order lacked details such as catheter size, type, and frequency of change. The treatment administration records for two months also did not specify these details, and the facility's policy on catheter care was not consistently followed. Observations revealed the resident's catheter tubing and drainage bag were stored under the wheelchair, with urine appearing cloudy. Nursing notes documented cloudy and foul-smelling urine, resident complaints of discomfort, and delays in obtaining a urinalysis due to a fax being sent to the wrong provider. The last documented catheter change was prior to admission, and there was confusion among staff regarding the frequency of catheter changes and the need for specific physician orders. The resident experienced discomfort and mucousy discharge upon catheter change, and a urinalysis was eventually collected after the new catheter was inserted. Interviews with nursing staff and the DON confirmed a lack of clear orders for catheter size and change frequency, as well as uncertainty about follow-up with urology. The facility's policy required observation and reporting of complications associated with urinary catheters, but this was not consistently implemented. The administrator acknowledged that orders for catheter care and documentation should have been in place, and the care plan should have reflected the use and management of the urinary catheter.
QAPI Meetings Lacked Required Members
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) group included the minimum required members at its quarterly meetings. Review of QAPI attendance records since the last recertification survey showed that the Medical Director was present at only one meeting, despite multiple meetings being held during the review period. During an interview, the Administrator acknowledged that the facility's QAPI policy does not specify which members must be present at the quarterly meetings and was unable to provide documentation to confirm the Medical Director's attendance at more than one meeting. The facility reported a census of 51 residents at the time of the review.
Failure to Follow Infection Prevention Protocols for Residents with Indwelling Urinary Devices
Penalty
Summary
The facility failed to follow infection prevention protocols for two residents with indwelling urinary devices. For one resident with a urostomy and colostomy, staff did not consistently use Enhanced Barrier Precautions as required. During care, a CNA donned appropriate personal protective equipment (PPE) when emptying the colostomy bag but failed to wear an isolation gown when emptying the urostomy bag, despite facility expectations and staff interviews confirming that a gown, gloves, and face shield should be used. Additionally, the resident's care plan lacked specific direction regarding Enhanced Barrier Precautions during device care, and the facility's catheter care policy did not address the need for such precautions for residents with indwelling urinary devices. For another resident with a suprapubic catheter, a nurse cleansed the catheter insertion site while wearing gloves but did not change gloves before applying a new dry dressing, contrary to facility expectations and staff interviews. The nurse acknowledged forgetting to change gloves during the observed care. The facility's policy on suprapubic catheter care did not include steps for applying a clean dry dressing, contributing to the lack of adherence to infection control protocols.
Delayed Treatment for Eye Infection
Penalty
Summary
A deficiency occurred when the facility failed to initiate timely treatment for an eye infection in a resident with severe cognitive impairment and a diagnosis of non-Alzheimer's dementia. On one occasion, the resident's family alerted a nurse to symptoms including a swollen, reddened, and draining right eye, with the resident also reporting itchiness and pain. The nurse documented the symptoms and completed a communication form for the provider, but there was no documented response from the nurse practitioner or physician at that time. It was not until several days later, after another family member again raised concerns about the resident's eye, that a registered nurse assessed the resident and contacted the physician, resulting in an order for antibiotic eye drops. The delay in provider notification and initiation of treatment did not align with professional standards of practice, as the resident's symptoms persisted for several days before appropriate medical intervention was started.
Deficiency in Food Palatability and Presentation
Penalty
Summary
The facility failed to serve food in an attractive and palatable manner during meal services, as observed during a survey. On one occasion, a sample lunch tray provided to the State Agency included a chicken patty and green beans. The chicken patty was noted to have hard, tough, and chewy edges, while the green beans were acceptable. Additionally, a puree version of the green beans served to a resident appeared to be of a soup consistency. Resident #7, who had an intact cognitive status and was independent in most activities, reported that the chicken patty was hard and difficult to cut, and mentioned that meats served are often hard. On another occasion, a sample lunch tray included spaghetti, mixed vegetables, and a seasoned breadstick. While the food was served at a palatable temperature, the mixed vegetables were described as bland. Resident #1, who also had an intact cognitive status but required moderate assistance with daily activities, complained about the meal, noting that the mixed vegetables were bland and the meal consisted mainly of carbohydrates. Both residents had significant medical histories, including conditions such as congestive heart failure and diabetes mellitus.
Failure to Implement Physician's Wound Dressing Orders
Penalty
Summary
The facility failed to implement a physician's order to change the type of wound dressing for a resident with wounds. The resident, who has a history of necrotizing fasciitis, diabetes mellitus, and wound infection, was admitted with two Stage III pressure ulcers and surgical wounds. The resident required assistance with certain activities of daily living and had specific physician orders for wound care, including the use of Vashe wound sol therapy and specific dressings for the left heel and buttock wounds. Despite the physician's orders being documented on 11/1/24, the clinical record did not show evidence of these orders being implemented. Interviews with staff revealed a lack of awareness and communication regarding the new dressing orders. Staff B, a registered nurse, did not see the new dressing orders in the electronic medical record and was unsure why they were not processed. Staff A, an advanced registered nurse practitioner, was not informed about the unavailability of supplies or the failure to implement the new dressing orders. Staff C, another registered nurse, was unclear about the wound dressing orders and assumed the night or weekend nurse would handle them. The facility's administrator and director of nursing expected the orders to be entered into the computer and implemented promptly. However, the process for handling and recording treatment orders was not followed, leading to the deficiency. The facility's policy on medication orders outlined the need for specifying treatment, frequency, and duration, but this was not adhered to in this case.
Inconsistent Advance Directive Procedures
Penalty
Summary
The facility failed to maintain a consistent plan and procedure for advance directives for six residents. The deficiencies were identified through observations, clinical record reviews, and staff interviews. For Resident #9, the electronic health record (EHR) did not indicate a code status, and a Full Code magnet was incorrectly placed on the door, indicating the wrong bed. Similarly, Resident #17's Full Code magnet was placed on the wrong side of the door, indicating the incorrect bed. Resident #19's EHR indicated a Do Not Resuscitate (DNR) status, but a Full Code magnet was incorrectly placed on the door, and staff were unaware of the magnet's significance. Resident #34's EHR indicated a Full Code status, but there was no magnet on the door, and staff were initially unaware of the resident's code status. Resident #42 also lacked a magnet on the door despite being a Full Code, as verified by staff. Resident #60's EHR failed to indicate a code status, and there was no signed Policy for Resuscitative Services document. Additionally, there was no Full Code indicator magnet outside the resident's room. The facility's administrator acknowledged the issues with the advance directives and expressed concerns about the accuracy and reliability of using magnets to indicate code status. The administrator mentioned plans to discuss the potential removal of magnets with the Director of Nursing (DON) due to the difficulty in maintaining their accuracy and the possibility of residents moving them.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to conduct Monthly Drug Regimen Reviews for the month of July, affecting all 56 residents. During a review of the monthly pharmacy reviews, it was discovered that no reviews were performed for any residents in July. On September 10, the Administrator confirmed that no pharmacy review was conducted in July and presented an email from a Consultant Pharmacist. This email, dated August 8, indicated that the Consultant Pharmacist noted the absence of completed recommendations from July and re-issued any relevant recommendations. The facility's policy, dated 2006, mandates that a consultant pharmacist perform a comprehensive medication regimen review at least monthly, which includes evaluating the resident's response to medication therapy and reporting findings to the director of nursing, attending physician, medical director, and, if appropriate, the administrator.
Insufficient Nursing Staff Leads to Admission Process Issues
Penalty
Summary
The facility failed to provide sufficient qualified nursing staff to meet the needs of its residents, as evidenced by interviews and document reviews. Staff C, an RN, highlighted issues with the admission process, noting that there is often only one nurse on the floor per shift, which hampers the ability to complete admissions properly. The absence of an Assistant Director of Nursing (ADON) has further complicated the process, leading to delays in reviewing and confirming admission orders. The Director of Nursing (DON) expressed concerns about staffing levels, indicating that the facility operates with minimal staff, which has resulted in administrative staff, including the Administrator, having to fill in for nursing duties. This situation has led to staff burnout and raised concerns about the safety of both residents and staff. The facility's staffing issues are further corroborated by the Center for Medicare and Medicaid Services PBJ Staffing Data Report, which triggered a One Star Staffing Rating and noted excessively low weekend staffing. The facility's policy, revised in October 2017, states that sufficient numbers of staff with the necessary skills and competencies should be available to meet resident needs. However, the review of daily nursing schedules from August to September 2024 revealed that staffing levels were inadequate, particularly during night shifts and weekends, when the facility had a census of 56 residents. This deficiency in staffing has impacted the facility's ability to provide timely and safe care, as well as to promote the residents' rights and well-being.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation protocols during meal service and food storage. During an observation, it was noted that a cook did not change gloves at appropriate times, handling various surfaces and food items without changing gloves, which could lead to contamination. Additionally, a refrigerator used for resident food storage lacked a thermometer and temperature log, and contained expired and undated food items such as shredded lettuce, whipped cream, mozzarella cheese, eggs, and yogurt. This indicates a failure to ensure that resident food was stored at appropriate temperatures and that expired food was removed. Furthermore, the facility did not maintain proper dish sanitation practices. The dishwasher log, which was supposed to record safe wash and rinse temperatures three times a day, lacked many entries, particularly in the evenings. The dishwasher was required to operate at specific temperatures for effective sanitation, but the log did not consistently reflect this. Additionally, cups used for service appeared to have a white film, suggesting inadequate cleaning. These deficiencies highlight lapses in the facility's adherence to its own policies regarding food storage and dish machine use, which require regular temperature checks and proper labeling and dating of food items.
Repeat Deficiencies in QAPI Process
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies. This resulted in multiple repeat deficiencies identified during the current recertification and complaint survey, which were also noted in surveys conducted over the past six months. The deficiencies were related to resident rights and dignity, reasonable accommodation of needs, services meeting professional standards, bowel and bladder incontinence or catheter use, sufficient nursing staff, psychotropic drug use, food procurement, storage, service, and sanitation, and the QAPI program itself. The facility's QAPI program, as outlined in their policy revised in February 2020, was intended to measure and improve outcomes of care and quality of life, establish performance improvement projects, and monitor corrective actions. However, despite these objectives, the facility continued to have repeat deficiencies in the same areas. The Administrator acknowledged these ongoing issues and indicated that the facility's Quality Assurance Committee meets monthly to review concerns, but the repeat deficiencies suggest that the QAPI process was not effectively addressing the identified problems.
Failure to Implement Gradual Dose Reduction for Antidepressant
Penalty
Summary
The facility failed to implement a Gradual Dose Reduction (GDR) for a resident taking Duloxetine, an antidepressant medication, despite multiple recommendations from a consultant pharmacist and agreement from the resident's primary provider. The pharmacist initially recommended reducing the dose from 40 mg to 30 mg in November 2023, and the provider agreed to this recommendation. However, the facility did not update the Medication Administration Record (MAR) to reflect this change, and the resident continued to receive the higher dose. Throughout several months, the consultant pharmacist repeatedly noted that the dose reduction had not been implemented, despite the provider's agreement. The pharmacist's reports from January, March, April, and May 2024 all documented that the MAR still listed the 40 mg dose, and the pharmacist continued to recommend updating the MAR to the correct dosage. A handwritten note by an LPN indicated that the resident's family disagreed with the dose reduction, but there was no documentation from the prescriber supporting the family's wishes over the agreed-upon GDR. The resident's care plan noted the family's disagreement with the GDR, but the facility was unable to provide documentation from the prescriber to justify not following through with the dose reduction. The administrator acknowledged the oversight and confirmed that the provider had agreed to the GDR, but the order was never implemented. The resident had a documented Brief Interview for Mental Status (BIMS) score indicating intact cognition, raising questions about the decision-making process and the lack of documentation supporting the family's influence over the medication regimen.
Failure to Respect Resident's Choice of Caregiver
Penalty
Summary
The facility failed to respect a resident's choice of caregivers, leading to a deficiency in honoring the resident's rights to dignity and self-determination. Resident #18, who had intact cognition and a history of anxiety disorder, depression, and neuropathy, expressed a preference not to be assisted by a specific CNA, Staff F, due to perceived rudeness and meanness. Despite this, the resident reported that Staff F continued to assist with care, contrary to the resident's wishes and assurances given by the facility that the CNA would not return to the resident's room. The facility's failure to adhere to the resident's preferences was documented through multiple entries in nursing progress notes and behavior logs, which indicated repeated refusals of care by the resident and complaints about the CNA's behavior. The facility's policy on resident rights, which includes the right to choose providers and voice grievances, was not upheld in this instance, as evidenced by the continued involvement of Staff F in the resident's care despite the resident's explicit objections.
Failure to Ensure Accessibility and Functionality in Resident's Room
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by not ensuring accessibility to a hand washing sink and a functioning overhead lamp in the resident's room. The resident, who had intact cognition but moderate hearing difficulty and limited vision, reported being unable to maneuver their wheelchair into the bathroom to access the sink. Additionally, the resident experienced issues with the over-bed lamp, which required excessive force to operate and often did not work. These issues were observed during a survey, and the resident expressed their concerns to staff members. Despite the resident's grievances, the facility's maintenance staff reported that no work orders had been submitted regarding the sink accessibility or the malfunctioning lamp. The facility's policy on resident rights, which includes the right to voice grievances and have them addressed, was not adhered to in this case. Staff members were aware of the resident's difficulties but did not take appropriate action to resolve the issues, leading to the deficiency noted in the report.
Medication Management Failures for Two Residents
Penalty
Summary
The facility failed to ensure that basic nursing principles were followed for two residents, leading to significant deficiencies in care. Resident #9 was readmitted to the facility from a hospital stay, but the primary provider was not informed of the readmission. As a result, Resident #9 did not receive several critical medications, including those for stroke prevention, diabetes management, and depression, among others. Interviews with staff revealed that the medication orders from the hospital discharge were not properly reviewed or transcribed, leading to a lapse in medication administration. Resident #20, who was under hospice care and actively dying, was prescribed liquid morphine for pain management. However, the facility did not obtain a bottle of liquid morphine for this resident. Instead, Staff C administered morphine from another resident's bottle, which was against facility policy. The DON later confirmed that liquid morphine was available in the facility's emergency kit, but Staff C was unaware of this resource. This oversight resulted in the improper administration of medication to Resident #20. The report highlights the facility's failure to maintain proper communication and medication management protocols, as evidenced by the lack of notification to the primary provider and the inappropriate use of another resident's medication. These deficiencies were acknowledged by the facility's staff, including the Facility Administrator, Nurse Practitioner, and DON, who recognized the errors in medication administration and the need for adherence to established policies.
Failure to Follow Catheter Balloon Size Orders
Penalty
Summary
The facility failed to adhere to the Provider's orders regarding the indwelling catheter balloon size for a resident with a neurogenic bladder and urinary retention. The resident's care plan specified the use of a 16 French catheter with a 10 mL balloon, which was confirmed by a telephone order. However, the Medication/Treatment Administration Record indicated the use of a 15 mL balloon, and a subsequent urology appointment revealed that a 30 mL balloon was in place, which was incorrect and could cause complications. The resident experienced bladder pain and reported that the catheter was not functioning properly. The urology provider noted that the incorrect balloon size could lead to the catheter sitting too high in the bladder, preventing proper drainage. Despite the resident's complaints of abdominal pressure, the facility staff did not follow the specified orders, as confirmed by the Director of Nursing, who expected adherence to the Provider's instructions. The facility's catheter care policy required staff to review the care plan for any special needs, which was not followed in this case.
Failure to Resubmit PASRR Level 2 Approval Timely
Penalty
Summary
The facility failed to resubmit a short stay approval for a Pre-Admission Screening Resident Review (PASRR) level 2 within the appropriate time frame for one resident. The resident, who had a Minimum Data Set (MDS) indicating intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was diagnosed with Bipolar Disorder, Schizophrenia, and Dependent Personality Disorder. The resident required partial to moderate staff assistance and had a goal for discharge to return to the community. The care plan assigned the Director of Social Services the responsibility to contact local providers before the expiration of the time-limited PASRR determination, which was set to end on a specific date. However, the PASRR level 2, which initially approved a 180-day short stay due to the resident's health status and anticipated support needs, expired without a timely resubmission. The Facility Administrator acknowledged the expiration and indicated that a new submission would be sent immediately.
Deficiencies in Resident Assessment and Intervention
Penalty
Summary
The facility failed to conduct proper assessments and interventions for two residents experiencing changes in their conditions. Resident #10, who had a history of diabetes mellitus, experienced hypoglycemia with a blood glucose level of 60 mg/dL. Despite initial interventions with glucagon packets and orange juice, the resident's blood glucose level only rose to 75 mg/dL, prompting further intervention with an intramuscular glucagon injection. However, there was a lack of documented assessments between the initial incident and the subsequent transfer to the hospital, indicating a deficiency in monitoring and documentation. Resident #209, who was recently admitted and had not yet completed an MDS assessment, experienced constipation for several days. Despite the resident's report of not having a bowel movement for five days, the facility's bowel protocol was not effectively implemented. The resident received Milk of Magnesia and an enema, but there was no record of receiving Senna-time tablets as ordered. The facility's staff failed to notice the issue on the third day, and the resident did not have a bowel movement from April 25 to May 2, highlighting a deficiency in following the bowel management protocol. The facility's policy on conducting accurate resident assessments was not adhered to, as evidenced by the lack of documentation and timely interventions for both residents. The Assistant Director of Nursing acknowledged the need for more thorough documentation and adherence to protocols, particularly in monitoring residents' conditions and ensuring that all necessary interventions are carried out as per the care plans and physician orders.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to implement timely interventions for residents identified at high risk for pressure ulcer development and to prevent worsening of wounds. For Resident #20, the facility did not consistently monitor, stage, or measure wounds. The resident developed a deep tissue injury to the right heel and a stage two pressure ulcer to the coccyx. The care plan for Resident #20 was not adequately followed, as evidenced by the lack of documentation for treatment to the coccyx and inconsistent wound measurements. Observations revealed that the resident's wounds were not properly assessed or documented, and there was confusion among staff regarding who was responsible for measuring and staging the wounds. Resident #208 was admitted with multiple pressure ulcers, including a stage four pressure ulcer on the right hip, a stage three pressure ulcer on the left heel, and a stage two pressure ulcer on the right ankle. The facility failed to thoroughly assess these wounds upon admission and did not consistently monitor, stage, or measure them. The resident reported that the facility only measured his wounds twice, despite his understanding that his insurance required weekly measurements. Interviews with staff revealed a lack of clarity and consistency in the documentation and assessment of the resident's wounds. The facility's policy on skin and wound management was not effectively implemented, as evidenced by the lack of consistent wound assessments and documentation. Staff interviews indicated confusion and miscommunication regarding the responsibilities for wound care and documentation. The facility did not have a dedicated wound care nurse, and the responsibility for wound assessments was not clearly assigned, leading to inadequate monitoring and treatment of pressure ulcers for the residents involved.
Failure to Prevent Falls and Ensure Safety
Penalty
Summary
The facility failed to ensure an environment free of accidents and hazards for several residents, leading to multiple falls and injuries. Resident #42, who had impaired cognition and was at risk for falls, experienced several falls resulting in injuries, including a fracture of the right hip. Despite being identified as at risk for falls, the care plan for this resident lacked timely interventions, and the facility did not implement adequate supervision or preventive measures. The resident continued to fall even after returning from the hospital, indicating a lack of effective fall prevention strategies. Resident #19, with moderately impaired cognition and a history of falls, also experienced a fall resulting in a right hip fracture. The resident self-transferred despite needing assistance, and the facility's interventions, such as the use of alarms, were not effective in preventing the fall. Staff interviews revealed that the resident was non-compliant with using the call light and often attempted to self-transfer, which contributed to the fall. Resident #211, who had intact cognition but required assistance with wheelchair locomotion, was observed being pushed in a wheelchair without both foot pedals in use. This practice was against the facility's policy of ensuring foot pedals are used when pushing residents in wheelchairs. Additionally, Resident #18, who was rarely understood and had a history of falls, experienced multiple falls due to attempting to sit in chairs and missing them. The facility's interventions, such as ensuring proper footwear and using a Broda chair, were not sufficient to prevent these falls.
Failure to Address Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to develop and implement interventions to prevent or treat weight loss for several residents. Resident #52, who had diagnoses including dementia and adult failure to thrive, experienced a significant weight loss of 6.81% over a short period. Despite this, the care plan did not address the weight loss, and there was no documentation of provider notification or further interventions from mid-April until the survey. Observations showed the resident was not eating meals, and staff interviews revealed a lack of communication and action regarding the resident's nutritional needs. Resident #13, with moderately impaired cognition and a history of depression and dementia, also experienced significant weight loss. The care plan included interventions for dysphagia and a mechanically altered diet, but the resident's weight continued to decline. The resident did not receive prescribed supplements on multiple occasions due to unavailability, and there was a lack of documentation regarding the weight loss in provider notes. Interviews indicated that the resident was not given meal options or sufficient encouragement to eat, contributing to the ongoing weight loss. Residents #18 and #34 were also affected by the facility's failure to provide ordered dietary supplements. Both residents had numerous instances in April where their supplements were marked as unavailable. The Assistant Director of Nursing acknowledged issues with back-ordered supplements and delays due to changes in suppliers. This lack of availability contributed to the residents not receiving necessary nutritional support, further highlighting the facility's deficiencies in managing residents' nutritional needs.
Inconsistent Access to Resident Funds
Penalty
Summary
The facility failed to ensure a process was in place to allow consistent access to resident funds outside of business hours for five residents who participated in the trust fund. During a review of facility documents, it was revealed that these residents utilized the trust fund. When queried, the Business Office Manager (BOM) stated that she would provide funds to residents if they asked. However, the Administrator acknowledged that money had not been consistently available 24 hours a day, although there had been some access on weekends. The facility's policy on the protection of resident funds indicated that residents should have access to their money in a reasonable time and in the form requested, but this was not consistently implemented.
Inadequate Staffing Leads to Multiple Care Deficiencies
Penalty
Summary
The facility failed to provide adequate staffing, resulting in several deficiencies affecting the care of multiple residents. Resident #19, who had moderately impaired cognition and required assistance with transfers due to recent shoulder surgery, experienced a fall with injury. The incident occurred when a CNA was delayed in responding to the resident's call light due to attending to another resident, leading to Resident #19 attempting to transfer independently and falling. Resident #207, with intact cognition but dependent on staff for transfers, reported significant delays in receiving assistance for toileting needs. The resident experienced an incontinent episode after waiting several hours for a bedpan, highlighting the facility's inability to respond promptly to call lights due to insufficient staffing. Additionally, the resident noted that staff failed to inquire about toileting needs during meal delivery, further contributing to the incident. Other residents, such as Resident #10 and Resident #28, also reported long wait times for assistance, impacting their daily living activities. Resident #10, who used a wheelchair and required assistance for transfers, often remained in bed due to delays in staff response. Resident #28, with intact cognition, missed several scheduled showers due to staffing issues, as confirmed by the Assistant Director of Nursing. Furthermore, Resident #12, with severely impaired cognition, was observed struggling to eat without receiving the necessary assistance and cueing from staff, despite being present in the dining area.
Dietary Service Deficiency in Meal Preparation
Penalty
Summary
The facility failed to ensure that residents receiving mechanical soft and pureed diets were served meals in accordance with the prescribed menu. Specifically, 18 residents on a mechanical soft diet did not receive the correct meal portions as outlined in the Week 2 Tuesday Menu, which specified servings of beans, ground meat, soft garlic bread, and vegetables. Additionally, 6 residents on a pureed diet did not receive pureed bread as required by the menu. The Dietary Manager acknowledged these discrepancies during the meal service. The Dietary Manager was observed preparing meals by cutting hot dogs into chunks and processing them to a ground consistency, then combining them with baked beans without measuring the total volume of the mixture. This resulted in an excess of over 5 servings of food after serving the mechanical soft diet meals. Furthermore, the pureed diet meals were served without the required pureed bread. The facility's policy for mechanically grinding food was not followed, as it directed staff to measure the total volume of food and divide it by the original number of servings, which was not done in this instance.
Inadequate Kitchen Sanitation and Infection Control
Penalty
Summary
The facility failed to maintain adequate kitchen sanitation and infection control measures during food service, as observed during a kitchen tour and meal service. The dishwashing machine was found to be operating at a wash temperature of 108 degrees Fahrenheit, significantly below the required 155 degrees Fahrenheit, and lacked testing strips to verify its functionality. The machine also had a heavy buildup of a white substance and black stains on the surrounding floor. Additionally, the handwashing sink in the kitchen was cold to the touch, and there was a significant accumulation of dust and food debris in various areas, including the shelf above the stove burners, the fire suppression system, and the microwave. During the noon meal service, further deficiencies were noted, including the continued use of the cold handwashing sink by staff, and the presence of food smears and dust in the kitchen. The Dietary Manager was observed wearing gloves while touching various surfaces and items, including her facial mask, and then serving food and drinks to residents without changing gloves, indicating a failure to follow proper infection control protocols. These observations highlight significant lapses in maintaining sanitary conditions and preventing cross-contamination in the facility's food service operations.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for a resident with severely impaired cognition, as observed during two meal times. The resident, who required setup assistance and occasional cues, was left unassisted during lunch. Despite having a built-up utensil and pureed food, the resident did not eat and was not provided with encouragement or assistance by the staff. Observations noted the resident with eyes closed and arms crossed, and later attempting to eat with the spoon upside down, indicating a lack of proper assistance. During breakfast, the resident was observed sitting alone with spilled liquid on her lap and dripping to the floor. Despite the presence of staff, the resident was not assisted and continued to struggle with eating, using the handle of her adaptive fork to lick food. The resident remained unassisted for a significant period, highlighting a failure in providing timely assistance and maintaining the resident's dignity during meals.
Failure to Accommodate Resident's Bathroom Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident #16, by not individualizing the physical space of the resident's bathroom to ensure independent functioning, dignity, and well-being. Resident #16, who has an acquired absence of the left leg above the knee, pain in the right shoulder, and chronic obstructive pulmonary disease, was assessed to have intact cognition with a BIMS score of 14 out of 15. The resident required supervision or touching assistance for oral hygiene but was able to complete oral hygiene independently and took care of his dentures himself. After moving to a new room on December 5, 2023, the resident reported issues with the bathroom being too small to reach the sink, which was documented in an IDT Resident Care Conference note on December 7, 2023. However, there was no further documentation of any solutions discussed regarding the resident's bathroom concern. On April 29, 2024, the resident expressed dissatisfaction with the bathroom, demonstrating that he could not get within one foot of the sink, making the faucets and sink basin unreachable. The Assistant Director of Nursing (ADON) acknowledged that the bathrooms were not very large and sometimes wheelchairs did not fit, but she was unaware of any resident, including Resident #16, being unable to access the sink. The facility's policy on Accommodation of Needs, dated December 1, 2023, stated that reasonable accommodations would be made for individual needs and preferences, yet this was not reflected in the actions taken for Resident #16.
Failure to Provide Meal Options to Cognitively Intact Resident
Penalty
Summary
The facility failed to provide a resident with meal options, violating the resident's right to self-determination and choice. Resident #10, who was cognitively intact as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS) exam, did not receive a menu or meal options despite being on a regular/general diet with specific texture and consistency requirements. The resident expressed dissatisfaction, stating that he was not given choices because of his diabetes and that no one asked him what he wanted to eat. Interviews with staff revealed a lack of communication and oversight regarding the resident's meal preferences. The Dietary Manager admitted that Resident #10 did not receive a menu or options, mistakenly believing he did not want one. The Assistant Director of Nursing (ADON) confirmed that the resident had not received a menu during her tenure, attributing it to a period when the resident was very sick and did not choose options. Despite the resident's improved condition, the practice of offering a menu was not reinstated. The facility's policy on resident self-determination emphasized the resident's right to make choices about significant aspects of their life, which was not upheld in this case.
Failure to Notify Resident of Medicare Coverage Termination
Penalty
Summary
The facility failed to notify a Medicare Part A beneficiary, identified as Resident #8, of the termination of their coverage. This deficiency was identified through a clinical record review, staff interview, and policy review. The Beneficiary Notice-Residents discharged With the Last Six Months form indicated that Resident #8 was discharged from Medicare Part A on January 19, 2024. However, during an email correspondence on May 2, 2024, the Assistant Director of Nursing (ADON) admitted that the facility could not locate a discharge notice for Resident #8. The ADON also mentioned that at the time of the discharge, the facility had a different Social Services Director. According to the facility's policy on Beneficiary Notices, effective April 15, 2018, the facility is required to notify beneficiaries when their skilled nursing services and/or therapy services are ending and inform them of their right to request an appeal.
Deficiencies in Staff Background Checks and Training
Penalty
Summary
The facility failed to ensure that staff background checks were completed prior to the hire date for one of five staff members reviewed, and also failed to ensure that the dependent adult abuse mandatory reporter training was current for another staff member. Specifically, Staff C, an RN, was hired on 10/26/23, but her background check was not completed until 4/29/24. Additionally, Staff D, a CNA, did not have documentation of the required mandatory reporter training, despite being hired on 11/8/22. During an interview, the Administrator confirmed that the expectation was for background checks to be completed before hiring and for mandatory reporter training to be current. The facility's abuse policy mandates background checks and training on abuse prevention, identification, and reporting requirements at the time of hire, annually, and as needed.
Inaccurate MDS Coding for Medications and Catheter Use
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) coding for several residents, leading to discrepancies in medication and treatment documentation. For Resident #3, the MDS assessment indicated the use of an anticoagulant, but the February 2024 Medication Administration Record (MAR) did not document the administration of such medication. Similarly, Resident #46's MDS assessment also indicated anticoagulant use, yet the March 2024 MAR lacked corresponding documentation. The Assistant Director of Nursing (ADON) acknowledged the need for accurate MDS coding and mentioned a misunderstanding regarding the classification of medications like aspirin as anticoagulants. Additionally, the facility failed to accurately document the presence of a Foley catheter for Resident #11. The MDS assessment indicated the resident was always incontinent and did not have an indwelling catheter, despite hospice documentation confirming the presence of a Foley catheter. The ADON confirmed the oversight in documentation and coding. Furthermore, Resident #18's MDS assessment failed to reflect the administration of an antidepressant, despite a physician's order and MAR documentation showing daily administration of Mirtazapine for depression. The ADON acknowledged that Mirtazapine should have been coded as an antidepressant on the MDS.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered according to physician orders and professional standards for three residents. For Resident #11, who has severely impaired cognition and diabetes, insulin was administered without clear parameters for when to hold the medication. The resident's insulin was held on several occasions based on blood sugar levels, but the facility lacked specific guidelines for these decisions. Staff interviews revealed inconsistent practices and reliance on nursing judgment without proper physician notification. Resident #18, who rarely understands, was prescribed Levetiracetam, an anticonvulsant medication, but the care plan did not address its use. The medication was not available on multiple occasions, and there was a lack of documentation explaining why doses were missed. The Assistant Director of Nursing acknowledged the absence of a backup supply and the need for a stat delivery from the pharmacy, which was not utilized in a timely manner. For Resident #50, who has intact cognition and a diagnosis of COPD, the facility failed to ensure proper administration of a steroid inhaler. The resident did not rinse and spit after using the inhaler, as required. Additionally, the medication orders for potassium and isosorbide mononitrate lacked dosages, leading to uncertainty among staff about the correct administration. Interviews with staff and the Interim DON highlighted the oversight in confirming medication orders and the lack of adherence to special instructions for inhaler use.
Deficiencies in ADL Assistance and Care
Penalty
Summary
The facility failed to consistently provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in care. Resident #29, who has a self-care deficit due to multiple medical conditions including quadriplegia and a below-knee amputation, was observed with long, jagged fingernails and facial hair, indicating a lack of grooming care. Despite the care plan specifying assistance with bathing and grooming, the resident was not shaved or had their nails trimmed as required. Staff interviews revealed confusion about responsibilities for nail care and shaving, with the shower aide and CNAs expected to perform these tasks. Resident #12, with severely impaired cognition, was observed during meal times without receiving the necessary assistance and cueing for eating. Despite being assessed as independent for eating, the resident required setup assistance and encouragement, which was not provided. Observations showed the resident struggling to eat, with food and liquid spilled on their lap, and no staff intervened to assist during the observed meal times. Resident #28, who has intact cognition but requires assistance with bathing, reported missing several showers over the year, including a two-week period without a shower. Documentation confirmed gaps in bathing assistance, with the resident not receiving the scheduled two baths per week. The Assistant Director of Nursing acknowledged that showers were not consistently completed, although this was not attributed to staffing issues. The lack of adherence to care plans and inconsistent documentation contributed to the deficiencies in providing adequate care for these residents.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents, leading to deficiencies in documentation and infection control practices. Resident #11, who had severely impaired cognition, was observed with a Foley catheter, but the facility's documentation, including the Minimum Data Set (MDS) assessment and Medication Administration Record (MAR), did not reflect the presence of the catheter. The Assistant Director of Nursing (ADON) acknowledged the oversight, noting that the resident's family had decided to place the resident on hospice care, which necessitated the catheter. However, the facility's policy on catheterization did not address the specific issues observed. Resident #19, with moderately impaired cognition, was observed with catheter tubing touching the ground while seated in a wheelchair, which poses an infection control risk. The Care Plan and Physician Orders for this resident lacked documentation of an indwelling catheter. Interviews with Certified Nurse Aides (CNAs) and the ADON confirmed that catheter tubing should not touch the floor and should be secured to prevent urine backflow. The facility's failure to ensure proper catheter placement and documentation for both residents highlights significant lapses in care and infection control practices.
Duplicate Opioid Orders for a Resident
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically by having two active orders for the same opioid medication, hydrocodone/acetaminophen, for a resident reviewed for pain management. The resident, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status (BIMS) exam, was diagnosed with multiple sclerosis and had several pressure ulcers at different stages upon admission. The care plan included administration of pain medications as per orders to manage the resident's comfort, particularly due to the presence of pressure ulcers and the associated pain. The physician orders revealed two separate prescriptions for hydrocodone/acetaminophen, one for 2 tablets every 6 hours as needed and another for 1 tablet every 6 hours as needed. The April Medication Administration Record (MAR) documented instances where both orders were administered within the same 6-hour period, indicating a failure to adhere to the prescribed time frame. Interviews with staff, including a registered nurse and the Assistant Director of Nursing, confirmed awareness of the duplicate orders and the need for change. The facility's medication administration policy emphasized the importance of administering medications according to the orders, including verifying the right medication, dosage, time, and method before administration.
Failure to Implement Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) for two residents receiving psychotropic medications. Resident #28, who had intact cognition with a BIMS score of 15, was prescribed Trazadone for depression and insomnia. Despite a pharmacist's recommendation for a GDR, which the prescriber agreed to, the facility did not document any reduction in the medication dosage. The Assistant Director of Nursing (ADON) initially believed the reduction had occurred but later admitted the GDR was missed. Resident #13, with severely impaired cognition and a BIMS score of 6, was prescribed Duloxetine for depression. A pharmacist recommended a GDR from 40 mg to 30 mg, which the prescriber agreed to in November. However, the reduction was not implemented until January, as the medication administration record continued to list the dosage as 40 mg. The ADON was unaware of the delay and acknowledged that the GDR should have been implemented earlier. The facility's policy on psychotropic medications emphasizes the necessity of GDRs unless clinically contraindicated.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to offer bedtime snacks to two residents who desired them, despite their expressed preferences and the facility's policy. Resident #28, who has diagnoses including depression, diabetes, and non-Alzheimer's dementia, reported that staff did not offer him bedtime snacks, which he would like to receive. Documentation for April 2024 showed multiple dates where there was no record of snacks being offered to him. Similarly, Resident #46, with diagnoses of anxiety, depression, and muscle weakness, stated that she no longer received bedtime snacks, which were previously provided around 7:30 p.m. Documentation also showed numerous dates where snacks were not offered. Interviews with staff revealed that the failure to provide snacks was due to a combination of factors, including staff being too busy to offer snacks and a lack of available snacks following a change in the facility's corporate ownership. Staff members reported that they sometimes had to purchase snacks themselves due to shortages. The Dietary Manager acknowledged issues with snack availability due to budget considerations under the new management, although improvements were noted. The facility's policy, revised in July 2023, stated that all residents should be offered a bedtime snack, which was not adhered to in these cases.
Repeated Deficiencies in QAPI Process and Resident Care
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) process, resulting in multiple repeat deficiencies identified during the current recertification and complaint survey. These deficiencies were previously identified in surveys conducted over the last 19 months. The facility, with a census of 58 residents, received citations for dignity, professional standards not met, and food procurement, storage, preparation, and sanitation without actual harm. Additionally, a complaint survey revealed a harm level citation for accident hazards/supervision and a no actual harm citation for activities of daily living/maintain abilities. During a subsequent complaint and incident revisit survey, the facility received no actual harm level citations for accident hazards/supervision, dignity, and QAPI program/good faith effort. The current recertification survey resulted in a harm level deficient practice for accident hazards/supervision and no actual harm level citations for dignity, QAPI program/good faith effort, activities of daily living/maintain abilities, meeting professional standards, and food procurement, storage, preparation, and sanitation. The facility's QAPI plan, dated 9/12/13, outlined guidelines and performance improvement plans, but the repeated citations indicate a failure to effectively address and sustain improvements in these areas.
Failure to Ensure Adequate Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to ensure a surety bond was in place to cover the total amount of personal funds in the resident trust account for five residents who utilized the trust fund. The facility had a census of 58 residents. A document titled 'Residents who use the trust' revealed that five residents utilized the trust fund. The surety bond provided by the facility was dated 6/23/23 and had an amount of $40,000. However, on 5/02/24, the facility's Administrator confirmed that the total amount of resident funds exceeded the facility's surety bond. The facility's policy on the protection of resident funds required a surety bond on the cumulative total of all resident trust fund balances, which was not met in this case.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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