Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan - Indianola during CMS and state inspections, most recent first.
Food was not consistently held at the required hot temperature during meal service. A test tray showed mashed potatoes and carrots below the facility’s minimum standard, and two cognitively intact residents reported that meals were often cold, not always warm, and sometimes lacked a cloche cover when delivered.
Call lights were not kept within reach for two residents. One resident had intact cognition but needed staff help with bed mobility and transfers, had upper-extremity impairment, and was observed with the call light wrapped on the bed rail and later on the floor. Another resident with paraplegia, MS, weakness, and dependence for multiple ADLs was repeatedly observed without the call light within reach in bed and in a wheelchair, and stated she could not reach or see it.
Missing Belongings Not Properly Tracked or Followed Up: Two residents with intact cognition reported missing clothing and other personal items, and one resident’s family reported repeated loss of clothes, shoes, and a walker. Grievance forms showed staff looked in laundry, rooms, and lost and found, but no inventory forms were found for either resident and the record did not show a reliable system for tracking or following up on the missing belongings concerns.
Failure to document basis for transfer and provide required notice: A resident with severe dementia, dependence for most ADLs, and a history of behavioral concerns was transferred to an affiliated facility without medical record documentation supporting why the move was necessary. The record showed a prior hypersexual incident and later a resident-to-resident physical contact event, but no documented ongoing resident-to-resident sexual behaviors after that point. The resident's rep was told of the transfer and later the discharge, but there was no evidence that the required 30-day notice was given to the rep or the LTCSO, and no physician documentation supported the discharge rationale.
The facility failed to document bed-hold information for several residents sent to the hospital, including residents with MS, TBI, and severe cognitive impairment. In one case, staff contacted a resident’s representative after a change in condition, but there was no record that a bed hold was offered or discussed. The facility also lacked documentation that a resident, the resident’s representative, or the LTCSO received written advance notice of a planned discharge to another facility.
MDS and care plan PASRR documentation was not accurately completed for two residents with Level II PASRR status. Both residents had psychiatric diagnoses and notices showing approval for specialized services, but A1500 was marked no and A1510 was left blank, and the care plans lacked PASRR documentation. Staff interviews confirmed the residents were Level II PASRR residents and that the PASRR entries were incorrect.
A resident with anxiety disorder and psychotic disorder had a PASRR Level II with short-term approval and a required follow-up review, but the facility did not complete the time-limited PASRR within the required timeframe. The SS staff member reported she was unaware PASRRs needed to be tracked and resubmitted when approvals expired, and records showed the resident’s PASRR was not completed again until much later.
A resident who used tobacco was observed smoking without the apron required by the care plan, despite staff supervision and the resident’s cigarettes and lighter being kept at the nurse’s station. Staff interviews confirmed the care plan was expected to be followed, but aprons were not being used consistently during smoking, even though the facility policy required protective wear at all times for residents who needed it.
Improper Disinfection of Glucometer During Blood Sugar Checks. A CMA checked blood sugars for three residents and wiped the glucometer with an alcohol pad between checks instead of using the required disinfectant wipe. The CMA stated the proper wipes were not on the cart, and the DON stated staff should use disinfectant wipes and allow them to set for 5 minutes. Two residents involved had diabetes and orders for blood sugar checks before meals and at bedtime.
The facility failed to provide adequate nursing staff, particularly on night and weekend shifts, resulting in prolonged call light response times for multiple cognitively intact residents. With only three to four CNAs and two nurses caring for 82 residents across four halls, including an isolated rehab hall, residents reported routinely waiting 45 minutes to over an hour for assistance with toileting, hygiene, and going to bed, and some reduced their use of call lights because help did not arrive. Call light logs documented numerous delays ranging from about 18 minutes to more than two hours. Resident council minutes repeatedly noted concerns about insufficient staffing and delayed call light responses, while CNAs, an RN, and an LPN consistently described the facility as chronically short staffed at night and on weekends. The DON confirmed that the facility expected five CNAs on nights, a 15-minute call light response time, and acknowledged that current staffing and call light times were inadequate, with no clear chain-of-command process when the on-call manager was unavailable.
The facility was cited for repeatedly failing over several survey cycles to correct known staffing deficiencies despite an active QAPI focus on assuring appropriate staffing. Public state survey records showed multiple surveys over a multi-year period with cited staffing violations while the facility maintained a census of 82 residents. QAPI notes identified staffing as an ongoing action item, and the Administrator acknowledged that leadership had been aware of staffing needs prior to his tenure and that the issue represented a repeat failure, though earlier QAPI documentation was unavailable.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required. Surveyors found gaps in staffing and leadership coverage during their review.
Staff failed to maintain the dignity of two residents by not promptly changing a stained shirt and by responding abruptly to a request, leaving one resident feeling insignificant. Another resident with quadriplegia experienced repeated delays in receiving feeding assistance, often being the last to be served meals due to staff unavailability, despite her dependence on staff for eating. These deficiencies were confirmed through observations, resident and staff interviews, and review of facility policies.
A CMA left a cup containing a Senna tablet unattended on a locked medication cart while administering medications, with a resident in a wheelchair nearby. Facility policy requires all medications to be secured and not left accessible when staff are not present. The DON confirmed that medications should not be left unattended.
Staff did not disinfect a mechanical lift between uses for two residents, with CNAs transferring one resident and then another using the same lift without cleaning it in between. Disinfectant wipes were not available on the equipment or in resident rooms, and staff interviews revealed inconsistent disinfection practices and a lack of a specific written policy for cleaning reusable equipment.
A male resident with dementia and a history of hypersexual behaviors was able to enter a female resident's room and inappropriately touch her, despite known risks and prior incidents. The female resident, who had limited mobility and required assistance with ADLs, was asleep during the incident and did not recall it. Staff interventions, including monitoring and alarms, were not sufficient to prevent the abuse, and the care plan for the female resident did not address the risk of resident-to-resident incidents.
Staff did not have access to an accurate code status for a resident with multiple diagnoses and moderately impaired cognition. The binder at the nursing station contained an IPOST form directing CPR, while both the EHR and the IPOST indicated the resident wished to be DNR. The DON confirmed that IPOSTs in the binders were expected to be accurate.
A resident with impaired cognition and physical limitations experienced an incident where another resident entered her room and touched her inappropriately. The care plan was not updated to reflect the incident or to include interventions for her psychosocial and mental health needs, despite facility policy requiring such updates after changes in resident status.
Staff did not follow infection control protocols during incontinence care for a resident, allowing a clean brief to come into contact with urine-soiled bedding. In a separate case, staff failed to use required gowns during high-contact care activities for a resident with a suprapubic catheter and quadriplegia, despite facility policy and care plan directives for Enhanced Barrier Precautions (EBP).
A resident's bathroom floor remained persistently sticky over several days, with shoes sticking to the surface during multiple observations. Despite a policy requiring daily and routine thorough cleaning, the floor was not properly maintained, and staff were aware of issues with the cleaning solution concentration.
A resident with cognitive and physical impairments did not receive timely assistance with incontinence care or nail hygiene, as required by their care plan and facility policy. Staff failed to check or change the resident's incontinence brief for several hours, resulting in a saturated brief and urine odor, and the resident's nails remained untrimmed and dirty despite policy requiring regular care.
Staff failed to respond to call lights within the expected timeframe, with a resident waiting at least 10 minutes and staff repeatedly turning off the call light without providing assistance. Multiple residents reported long waits and inadequate responses. Additionally, a resident with cognitive and physical impairments did not receive timely incontinence care, remaining in a saturated brief for several hours despite care plan directives and facility policy. Staffing shortages contributed to these deficiencies.
The facility failed to provide sufficient staffing, leading to delays in resident care. Residents reported long wait times for assistance, and staff expressed being overworked and unable to take breaks. The facility was often short-staffed, contributing to increased falls and UTIs among residents.
The facility failed to maintain adequate nursing staff, resulting in the DON and ADON working the floor despite a census of 78 residents, exceeding the regulatory limit for a DON to serve as a charge nurse. Staffing files showed the DON worked the floor frequently, leading to her resignation due to burnout. The facility had a staffing contract with an agency but failed to utilize it, contributing to the staffing issues.
The facility failed to maintain appropriate food temperatures during meal service, as observed by surveyors. Residents reported receiving cold meals, linked to a malfunctioning steam table and non-operational plate warmer. The Dietary Cook and CDM confirmed these issues, which had been reported but not resolved. A sample tray showed food temperatures below required levels.
A resident with a high risk for falls experienced multiple falls due to inadequate supervision and care planning. The facility failed to perform a root cause analysis or update the care plan with fall interventions, resulting in repeated falls and a serious head injury. Staff interviews revealed issues with staffing levels and incident reporting, contributing to the deficiency.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed lymphedema pump treatments due to the facility's failure to process and implement physician orders accurately. Despite the presence of the pump in the facility, the treatment was not administered, as confirmed by staff interviews and record reviews.
A LTC facility experienced significant medication errors involving two residents. One resident accidentally ingested another's medications, leading to a severe drop in blood pressure and emergency treatment. Another resident received incorrect doses of a pain medication over several instances. Additionally, a nurse was observed leaving a medication cart unattended, with insulin pens and supplies accessible. These incidents highlight failures in medication administration and supervision.
The facility failed to provide adequate staffing, resulting in residents being left unsupervised and experiencing neglect, such as missed baths and long call light response times. Staff reported being overburdened and unable to perform their duties effectively, particularly during the evening shift. Previous incidents of unsupervised residents led to a resident-to-resident encounter requiring investigation.
The facility failed to maintain complete and accurate medical records, delaying surveyor access to necessary documents. The DON manually entered data due to incomplete records, and a resident was left unobserved for 56 minutes despite being on 15-minute checks. Issues with the electronic health records system and incorrect instructions further complicated the survey process.
The facility failed to notify the Ombudsman of resident transfers to the hospital for five residents, as required by regulations. This deficiency was identified through record reviews and staff interviews, revealing that notifications had not been completed from December 2023 to March 2024. The facility's policy did not include the requirement for such notifications, contributing to the oversight.
The facility failed to investigate and document grievances regarding missing cigarettes for several residents. Despite reports to staff, including the DON, the facility's grievance documentation was incomplete, and residents feared losing smoking privileges if they continued to voice concerns. The facility's policy requires documentation and investigation of grievances, which was not followed, leading to a deficiency.
A resident with multiple pressure ulcers did not receive consistent wound care, as treatments were not documented in the TAR. The resident reported inconsistent dressing changes, leading to severe drainage. Staff acknowledged the resident's noncompliance and adjusted care times, but the DON confirmed that undocumented treatments were considered not done. Facility policies on systematic assessment and documentation were not followed.
A resident with Parkinson's Disease, dementia, and Tourette's syndrome was administered antipsychotic medications without documented non-pharmacological interventions, violating the facility's policy. Staff interviews revealed inconsistent documentation practices, and the Director of Nursing expected documentation of three non-pharmacological interventions prior to PRN medication administration.
A facility failed to accurately complete an MDS assessment for a resident with multiple mental health diagnoses. The MDS did not reflect the resident's status as determined by the state level II PASRR process, which recommended specific support services. The care plan lacked information about PASRR completion and recommended resources, despite facility policies requiring such documentation.
The facility failed to maintain an updated PASRR for a resident with schizophrenia and depression, and did not incorporate PASRR service recommendations into another resident's care plan. One resident's PASRR was outdated and lacked necessary diagnoses, while another's care plan did not reflect PASRR findings despite having multiple mental health diagnoses and using psychotropic medications.
Two residents in an LTC facility did not receive their scheduled baths and grooming. One resident with Parkinson's and dementia had unkempt fingernails and was unshaven, with inconsistent bath documentation. Another resident with a stroke and pressure ulcers reported not having a bath for ten days, despite a thrice-weekly schedule. Staff interviews revealed documentation gaps and potential staffing issues.
A resident with multiple wounds did not receive proper infection control during a dressing change. An LPN failed to change gloves and sanitize hands between handling soiled dressings and clean supplies, contrary to the facility's infection control policy. The DON confirmed the expectation for staff to perform hand hygiene when moving from dirty to clean areas.
Food Served Below Required Temperature
Penalty
Summary
The facility failed to ensure hot foods were held at minimum required temperatures for one observed meal and for two interviewable residents who reported concerns about the food. During a meal observation on 5/13/26, a staff member prepared a test tray and placed it on a food cart in the kitchen, while meals continued to be plated and loaded onto the cart. The cart was then taken to the nursing station, and room trays were passed beginning at 12:30 p.m., with the last resident tray distributed at 12:34 p.m. When the surveyor checked the test tray, mashed potatoes measured 126 degrees Fahrenheit and carrots measured 131 degrees Fahrenheit, and the foods were described as warm but not hot. The Nutrition and Food Manager stated that food should be held at a minimum of 135 degrees Fahrenheit and wanted it above that, and the facility policy also reflected a temperature standard higher than 135.2 degrees Fahrenheit. Resident #50 had a Brief Interview for Mental Status score of 13, indicating intact cognition, and stated that he gets his food last and it is not always warm, and that the facility does not always use a cloche to cover the food when bringing it. Resident #47 had a Brief Interview for Mental Status score of 15, also indicating intact cognition, and reported that the food was often cold and tasteless. Resident #47 stated she did not look forward to the meals served at the facility.
Call lights not kept within reach for two residents
Penalty
Summary
The facility failed to ensure call lights were within reach for 2 of 20 residents sampled, including Resident #63 and Resident #72. Resident #63’s MDS showed a BIMS score of 13, dependence on staff for bed mobility and transfers, and impaired upper-extremity range of motion on one side. His care plan identified ADL deficits related to extremity weakness and paralysis and directed staff to modify the environment to maximize safety. During observation, the call light cord was wrapped on the bed handrail, and later the call light was found lying on the floor by the bed. Resident #63 stated he had trouble reaching the call light and had contractures to his hand and fingers. Resident #72’s MDS showed paraplegia, multiple sclerosis, muscle weakness, lack of coordination, dependence on staff for multiple ADLs and transfers, and a BIMS score of 14. Her care plan did not document call light use or that the call light should be kept within reach. During multiple observations, she was seen in bed and in her wheelchair without the call light within reach; it was noted lying over the bed railing, touching the floor, or placed behind her on the bed railing. Resident #72 stated she could not reach or even see the call light. Staff O was informed that she could not reach it and then gave it to her.
Missing Belongings Not Properly Tracked or Followed Up
Penalty
Summary
The facility failed to ensure a system for tracking and following up on residents’ concerns about missing personal belongings for 2 of 3 residents reviewed for personal property. Resident #6 had diagnoses of CVA, PTSD, and depression, and the MDS indicated intact cognition with a BIMS score of 15. The MDS also documented that care of personal belongings was very important to the resident. The resident’s family reported that many clothing items, a pair of black shoes, and a blue walker with a seat had gone missing over the prior year, and said the issue had been raised at a care conference but nothing came of it. No inventory form was found for Resident #6. A grievance form for Resident #6 documented missing clothing items, including colored t-shirts with pockets, white t-shirts, and six to eight white jockey shorts. The investigation noted that clothing was sent to laundry daily, laundry staff reported the resident’s laundry was delivered, and ancillary staff and the Administrator were aware of the concern and continued to look for the articles. Staff interviews showed that Social Services, CNAs, and Activities staff said they would fill out grievance forms, check rooms, laundry, and lost and found, and notify SS, the DON, and the Administrator when items were reported missing. However, staff also reported that inventory sheets were supposed to be kept at the nurse’s station, yet none were found there or in the SS office for Resident #6. Resident #47 also had intact cognition on the annual MDS, and the MDS indicated that personal belongings were very important to the resident. The resident reported that clothing sent to laundry did not come back, including dusty-rose pants with flowers on one leg that had been missing for 6 months, along with many other clothing items, and stated staff had been told but the items were never replaced. No inventory form was found for Resident #47. Staff interviews indicated the resident misplaced items often and staff frequently looked for missing belongings, but the record still lacked an inventory form for this resident. The facility policy stated concerns were high priority customer satisfaction issues and that staff would make prompt efforts to resolve grievances and keep the resident or representative apprised of progress, but the record reflected missing belongings concerns without a complete tracking system for these residents.
Failure to Document Basis for Transfer and Provide Required Discharge Notice
Penalty
Summary
The facility failed to document a sufficient basis for the discharge and transfer of a resident with severe cognitive impairment and a history of behavioral concerns to an affiliated facility. Resident #92 had a BIMS score of 3 out of 15, diagnoses including Alzheimer's disease, dementia with behavioral disturbances, and diabetes mellitus, and required extensive assistance with ADLs and mobility. The care plan identified impaired cognition and directed staff to use simple, direct communication and yes/no questions to determine needs. The record showed a hypersexual behavior toward a female resident on 2/23/25, followed by relocation closer to the nurses' station and other male residents. Later notes documented that the resident was no longer able to ambulate, medications were discontinued due to decline in health, and the medication used to control hypersexual behavior was restarted and later increased. A resident-to-resident physical contact incident occurred on 2/28/26, and subsequent notes indicated the resident was on 1:1 supervision with no sexual behaviors noted. However, the record did not contain progress notes documenting hypersexual behavior toward other residents after 3/2/26, despite staff statements that the transfer was related to ongoing behaviors. The resident's representative was notified that the resident was being transferred to an affiliated facility and later informed that the resident would be discharged there permanently. The representative stated she was unhappy with the decision and believed the medication had not been given enough time to work. The facility provided no documentation that the resident, the resident's representative, or the LTCSO received the required 30-day advance notice of transfer or discharge. Staff and leadership interviews indicated the transfer was pursued after unsuccessful referrals to other facilities and discussions with corporate and the receiving facility, but the medical record did not include physician documentation supporting the specific basis for the discharge or transfer.
Missing Bed-Hold Notices and Advance Discharge Notification
Penalty
Summary
The facility failed to provide bed-hold information for 3 of 3 residents who were admitted to the hospital. Resident #11 had multiple sclerosis, quadriplegia, neurogenic bladder, a suprapubic catheter, and a history of UTIs; she was transferred to the hospital for verbal unresponsiveness from baseline, a dilated pupil, and possible sepsis, and was admitted for a UTI and altered mental status. The documentation showed the family was notified, but it did not include that a bed hold was offered or discussed, and the Administrator stated there was no bed hold on file for this transfer. Resident #1 had a BIMS score of 10 out of 15 and diagnoses including diabetes mellitus and traumatic brain injury, with care plan documentation noting impaired cognitive function or thought processes related to the TBI. After a drop in oxygen level, the resident was sent to the hospital, and an eINTERACT SBAR note showed the nurse contacted the resident’s representative, but there was no documentation that a bed hold was offered or discussed. Staff stated bed holds were documented on paper, but the EHR did not include a bed hold or representative notification of the hospital transfer, and the Administrator confirmed the facility did not have that documentation. Resident #6 was readmitted from the hospital and later sent back to the hospital after the spouse called with concern the resident might have had a stroke; the resident was observed alert, oriented, and leaning to the left in a wheelchair, and the spouse requested hospital evaluation. The record lacked documentation that a bed hold was offered or discussed. Resident #92 had severe cognitive impairment with diagnoses including Alzheimer’s disease and dementia with behavioral disturbances, and was discharged to another facility owned by the same company after communication with the representative. The facility had no documentation that the resident, the representative, or the LTCSO was notified in writing and in a manner they understood at least 30 days in advance of the discharge.
MDS and care plan PASRR documentation not accurately completed
Penalty
Summary
The facility failed to accurately complete the MDS and comprehensive care plan for two residents reviewed for PASRR. Resident #22 had diagnoses of depression, bipolar disorder, anxiety disorder, and other hallucinations. Her MDS showed Question A1500 marked that she was not considered a Level II PASRR by the state Level II PASRR process, and Question A1510 lacked documentation. Her care plan initiated 1/25/21 also lacked documentation concerning Level II PASRR status. The Notice of PASRR Level II Outcome dated 9/19/24 indicated she was approved with specialized services and listed bipolar disorder, major depressive disorder, and paranoid disorder. Resident #72 had diagnoses of anxiety disorder and bipolar disorder. Her MDS showed Question A1500 marked that she was not considered a Level II PASRR by the state Level II PASRR process, and Question A1510 lacked documentation. Her care plan initiated 11/14/24 also lacked documentation concerning Level II PASRR status. The Notice of PASRR Level II Outcome dated 11/11/24 indicated she was approved with specialized services and listed dementia, anxiety disorder, and bipolar disorder. Staff interviews confirmed both residents were Level II PASRR residents, and the Social Services Coordinator stated she had incorrectly marked no on A1500 for Resident #22 and that PASRR documentation should have been on both care plans.
Failure to Complete PASRR Review Within Required Timeframe
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) within the required time-limited review timeframe for one resident reviewed for PASRR. Resident #63’s annual MDS documented diagnoses of anxiety disorder and psychotic disorder, and also showed the resident was receiving an antipsychotic and an antidepressant during the seven-day look-back period. A PASRR Level II determination dated 10/22/24 showed a short-term approval that ended on 2/19/25. During interviews, the Social Services staff member reported she had been in the role since 12/1/25 and was not aware she needed to complete PASRRs. She stated she later realized some PASRRs were only valid for 120 or 180 days and then had to be resubmitted, and that she was setting up a schedule for when PASRRs would be due. Review of the computer and PASRR vendor website showed Resident #63’s PASRR had last been completed on 10/22/24, a Level II PASRR was completed on 2/19/25 with a time-limited follow-up review needed, and the resident’s PASRR was completed again on 4/17/26.
Failure to Follow Smoking Apron Care Plan
Penalty
Summary
The facility failed to implement and follow the care plan for Resident #49, who had intact cognition on the MDS and was identified as a tobacco user. The revised care plan directed staff to place a smoking apron on the resident, store the resident’s cigarettes and lighter at the nurse’s station, and supervise smoking. A tobacco evaluation also indicated the resident required supervision for smoking, but it did not document smoking apron use. During observations, Resident #49 was seen smoking on the patio without an apron while seated in a motorized wheelchair, with staff present outside. On another observation, nine residents were smoking on the patio with Maintenance staff in attendance, aprons were hanging inside by the exit door, and none of the residents had aprons on while smoking; Staff K lit a cigarette for a resident. Interviews with the resident and staff showed the resident sometimes wore an apron but did not know why, and staff members stated they expected the care plan to be followed and that only Resident #49 and Resident #21 needed aprons when smoking. The facility’s smoking policy stated residents who need protective wear should wear it at all times when smoking.
Improper Disinfection of Glucometer During Blood Sugar Checks
Penalty
Summary
Provide and implement an infection prevention and control program. Based on observation, clinical record review, policy review, and staff interview, the facility failed to properly disinfect a glucometer for 2 of 3 residents observed during blood sugar checks. Resident #38 had a diagnosis of diabetes and a BIMS score of 14 out of 15, indicating intact cognition, and had an order to check blood sugar before meals and at bedtime. Resident #6 had a diagnosis of diabetes and a BIMS score of 11 out of 15, indicating moderately impaired cognition, and also had an order to check blood sugar before meals and at bedtime. During observation, Staff N, a CMA, checked Resident #55's blood sugar and wiped the glucometer with an alcohol pad, then checked Resident #38's blood sugar and again wiped the glucometer with an alcohol pad, and then checked Resident #6's blood sugar. After the blood sugar checks, Staff N stated she was supposed to wipe the glucometers with a disinfectant wipe but did not have those on her cart. The DON stated staff should use disinfectant wipes to sanitize glucometers and let the wipes set for 5 minutes. The facility policy directed staff to use a disinfectant or germicide wipe to sanitize a glucometer.
Inadequate Night and Weekend Staffing Leading to Prolonged Call Light Response Times
Penalty
Summary
The deficiency involves the facility’s failure to maintain adequate nursing staff on the overnight and weekend shifts, resulting in prolonged call light response times for multiple residents. Surveyors observed that during an overnight shift there were only three CNAs and two nurses in the building until an additional CNA arrived, bringing the CNA count to four for a building with four halls, including an isolated rehab hall staffed by only one person. The facility census was 82 residents. The DON later confirmed that the facility’s expectation was to have five CNAs on the overnight shift, and acknowledged that recent resignations and staff on paternity and maternity leave had led to operating with fewer staff than typical. The facility assessment stated that staffing was to be based on resident acuity and needs, feedback, and use of pool and agency staff as needed. Multiple cognitively intact residents reported long waits for assistance via call lights, particularly at night and on weekends. One resident who could not get to the bathroom independently stated that while daytime staffing was often sufficient, nighttime staffing was inadequate and call lights were not answered in a timely manner, leading him to feel he had to advocate for other residents. Another resident who was dependent for care reported waiting at least 45 minutes, and possibly over an hour, for assistance after soiling herself, describing this as a daily and nightly occurrence and noting that she felt miserable and ashamed having to sit in urine and feces. A third resident reported that call light response times were usually 45 minutes or longer, especially on nights and weekends, and that she had reduced how often she used her call light because help did not come; she also reported not reliably receiving water at night. Another resident stated that staffing was usually bad at night and that she typically waited over an hour for assistance with going to bed, with night and weekend staff frequently reporting they were short staffed. Objective call light response logs for several residents over a three-day period showed numerous instances of call lights remaining unanswered for extended periods, including times ranging from approximately 18 minutes to over two hours. Resident council minutes from two separate months documented ongoing resident concerns about insufficient staffing and a desire for call lights to be answered within 15 minutes, showing the facility had been made aware of these issues over time. Staff interviews across multiple CNAs, an RN, and an LPN consistently described the facility as always or frequently short staffed, especially at night and on weekends, with reports of operating with only one CNA per hall and sometimes only two to three CNAs total. Staff stated that the low staffing levels caused slow call light response times and made it impossible to be everywhere they were needed, with one nurse reporting that it could take 45 minutes or more to answer other call lights when they were already responding to one. The DON confirmed the expectation of a 15-minute call light response time and acknowledged that the recent call light times were unacceptable, and also stated there was no chain-of-command protocol when the manager on call was unavailable.
Repeated Failure to Correct Ongoing Staffing Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to make a good faith effort to correct ongoing deficient practices related to sufficient staffing over a three-year period. Review of the state agency’s public website showed multiple surveys ending on 07/29/2025, 04/24/2025, 01/30/2025, and 06/18/2025, each resulting in a deficiency cited for staffing while the facility reported a census of 82 residents. Quality Assurance and Performance Improvement (QAPI) meeting notes dated 12/15/2025 identified assuring appropriate staffing as an active area of the QAPI action plan, indicating that staffing concerns were formally recognized within the facility’s quality program. In an interview on 01/14/2026, the Administrator stated the facility had been aware of the need for more staff since before he assumed the role in November and acknowledged that the staffing issues were a repeat facility failure, though he could not explain why the failure persisted due to his limited tenure. He also reported that QAPI meeting notes from before December were unavailable, but that facility leadership had known about staffing issues for some time. No specific residents, clinical conditions, or direct resident care events are described in the report; the deficiency centers on repeated staffing violations and the facility’s failure over multiple survey cycles to effectively address and correct these known staffing problems through its QAPI and QAA processes.
Insufficient Nursing Staff and Lack of Licensed Nurse in Charge
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through surveyor observation and review of facility staffing practices. The report specifically notes the absence of adequate nursing coverage and the lack of a licensed nurse in charge during certain shifts, which did not meet regulatory requirements.
Failure to Maintain Resident Dignity and Timely Assistance with Meals
Penalty
Summary
Surveyors identified that staff failed to maintain resident dignity and timely care in several instances. One resident with intact cognition and a history of stroke, hemiplegia, and COPD was observed wearing a shirt stained with food after breakfast. The resident expressed discomfort about being in public with the stained shirt and stated she would have preferred to have it changed. Staff acknowledged the stain but did not change the shirt after transferring the resident to bed, and the resident remained in the stained shirt for an extended period. Additionally, when the resident requested to go outside to smoke, a staff member responded abruptly and dismissively, which made the resident feel insignificant. Another resident, also with intact cognition and diagnosed with multiple sclerosis and quadriplegia, required maximal assistance for eating. This resident routinely experienced delays in receiving assistance with meals, often being the last to be served because staff were not available to help her eat when she arrived in the dining room. The resident reported feeling neglected and believed staff prioritized other residents over her, particularly after the departure of a staff member who previously assisted her regularly. The issue was corroborated by interviews with dietary and clinical staff, who confirmed that the resident's meal was withheld until a staff member was available to assist, resulting in frequent delays. Facility records and staff interviews confirmed that both residents' concerns had been raised to management, and the issues persisted despite awareness among leadership. The facility's own policy emphasized the importance of maintaining resident dignity and providing necessary assistance, but observations and interviews demonstrated that these standards were not consistently upheld for the affected residents.
Unattended Medication Left Accessible on Medication Cart
Penalty
Summary
A Certified Medication Aide (CMA) was observed administering medications and left an opaque medication cup containing an orange, round pill (identified as Senna, a stool softener) unattended on top of a locked medication cart. During this time, the CMA walked away from the cart and into a resident's room, leaving the medication accessible. A resident in a wheelchair was observed nearby, three doors away from the unattended medication cart. The pill remained on the cart for several minutes while the CMA was away. Facility policy requires that all medications be secured in a locked medication cart, drawer, or cupboard, and not left accessible when staff are not present. The CMA confirmed that the medication should have been disposed of and not left unattended. The Director of Nursing (DON) also stated that medications should be secured in the medication cart or appropriately disposed of, and not left unattended.
Failure to Disinfect Mechanical Lift Between Resident Uses
Penalty
Summary
Staff failed to implement the facility's infection control policy by not disinfecting a mechanical lift between uses for two residents. On the observed date, Certified Nurse Aides (CNAs) transferred one resident from a wheelchair to a bed using a mechanical lift, then placed the lift outside the room without disinfecting it. Later, the same lift was used to transfer another resident without being disinfected beforehand. The lift was again placed in the hallway after use, still without being cleaned. Staff interviews revealed that disinfectant wipes (Saniwipes) were not available in resident rooms and were supposed to be stored either at the nurses' station or in storage pouches on the equipment, but none were found on the lift at the time of observation. Further interviews with staff indicated inconsistent practices regarding when and where reusable equipment was disinfected, with some staff stating that equipment was wiped down in the hallway after use or during the night, but not before being used for another resident. The Director of Nursing confirmed that staff were expected to disinfect the equipment between uses, but there was no specific written policy addressing the disinfection of reusable equipment such as mechanical lifts.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from abuse when a male resident with a history of dementia, impaired cognition, and documented hypersexual behaviors was able to enter the room of a female resident and inappropriately touch her. The male resident had a known pattern of sexually inappropriate behaviors, including previous incidents of touching other residents and staff inappropriately, making sexual remarks, and being noncompliant with medications prescribed for hypersexuality. Despite these behaviors, the care plan interventions, such as monitoring in hallways and use of alarms, were not sufficient to prevent the male resident from accessing other residents' rooms unsupervised. On the day of the incident, staff observed the male resident wandering the halls and entering female residents' rooms. Staff redirected him to his room, but he was later found in the female resident's room, sitting at the foot of her bed with her brief undone and his hand between her legs. The female resident, who had limited mobility due to a stroke and required assistance with ADLs, was asleep at the time and did not recall the incident upon waking. Staff immediately separated the residents and notified appropriate personnel, but the incident revealed that existing monitoring and supervision measures were inadequate to prevent resident-to-resident abuse. The care plan for the female resident did not include information about the risk of resident-to-resident incidents, despite her vulnerability due to physical limitations. Interviews with other residents indicated concerns about male residents entering female residents' rooms and a perception that staff response was not always timely. The report documents that the male resident's behaviors were known to staff, and interventions such as medication adjustments and increased monitoring had been attempted, but these measures did not prevent the incident of abuse.
Failure to Ensure Accurate Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that staff had access to an accurate code status for one resident reviewed for advance directives. Clinical record review showed that the resident had diagnoses including mild intellectual disabilities, heart failure, and depression, with a BIMS score indicating moderately impaired cognition. The facility's policy required advance directive orders to be kept in a binder accessible to nursing staff. During the survey, a registered nurse stated that code status would be checked first in the computer and then in the binder at the nursing station. However, the binder at the nursing station contained an IPOST form for the resident that directed staff to perform CPR, while both the electronic health record face sheet and the IPOST form itself indicated the resident wished to be DNR. The Director of Nursing confirmed that IPOSTs in the binders were expected to be accurate.
Failure to Update Care Plan After Resident-to-Resident Incident
Penalty
Summary
The facility failed to update and revise the care plan for a resident following a resident-to-resident incident involving inappropriate physical contact. The affected resident had a history of cerebrovascular accident (stroke), hemiplegia, muscle weakness, and impaired cognition, as indicated by a low BIMS score. The resident required significant assistance with activities of daily living and had documented symptoms of depression. Despite an incident in which another resident entered her room, undid her brief, and touched her inappropriately, the care plan was not updated to reflect this event or to include interventions addressing her psychosocial and mental health needs. Record review showed that the care plan, last revised after the incident, continued to focus on the resident's physical limitations and assistance needs but did not address the trauma or implement behavioral interventions related to the incident. Staff interviews confirmed that the care plan should have been updated to include the incident and related interventions. The facility's policy required care plans to be person-centered, updated as resident needs changed, and to include trauma-informed care, but these requirements were not met in this case.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow proper infection control practices during incontinence care for a resident with mild intellectual disabilities, heart failure, and depression. The resident, who required partial to moderate assistance with toileting hygiene and was incontinent of bowel and bladder, was observed lying on a soiled fitted sheet and bed pad. During care, staff changed the resident's incontinence brief before changing the soiled sheets, resulting in the clean brief coming into contact with urine-soiled bedding. Both the CNA and RN involved acknowledged that the clean brief was in contact with soiled sheets, which was contrary to facility policy and infection control standards. In a separate incident, staff did not implement Enhanced Barrier Precautions (EBP) for a resident with multiple sclerosis, neurogenic bladder, and a suprapubic catheter, who was also quadriplegic and dependent on staff for activities of daily living. Despite the care plan and facility policy requiring staff to wear gowns and gloves during high-contact care activities such as catheter care, changing briefs, dressing, and transfers, staff were observed performing these tasks without donning gowns. Specifically, staff emptied the resident's catheter bag, changed the resident's brief, assisted with dressing, and transferred the resident using a mechanical lift, all without wearing the required gown, though gloves were used. Interviews with staff and the Director of Nursing confirmed that the expectation was for gowns and gloves to be worn during high-contact care for residents requiring EBP, particularly those with indwelling catheters. Facility policies reviewed also supported these requirements, but observations showed that staff did not consistently adhere to them during the care of the resident with a catheter.
Failure to Maintain Clean and Non-Sticky Resident Bathroom Floor
Penalty
Summary
The facility failed to maintain a clean and non-sticky floor in the bathroom of one resident's room, as required by its housekeeping policy. Observations over three consecutive days revealed that the bathroom floor remained very sticky, with shoes noticeably sticking to the surface while walking. The facility's policy specified a daily cleaning schedule with routine thorough cleaning, but the persistent stickiness indicated that this was not effectively implemented for the resident's bathroom. The issue was identified through direct observation and confirmed by staff interviews, which acknowledged awareness of the problem and previous discussions about the cleaning solution concentration.
Failure to Provide Timely Incontinence and Nail Care
Penalty
Summary
A deficiency occurred when a resident with mild intellectual disabilities, heart failure, and depression, who required partial to moderate assistance with toileting hygiene, did not receive timely incontinence and nail care as directed by their care plan and facility policy. The resident was observed over a period of several hours without being offered assistance with toileting or incontinence care, despite care plan instructions to check and assist every two hours. The resident was later found with a heavily saturated incontinence brief and urine odor, and staff only provided care after being prompted by the surveyor. Staff interviews confirmed that the resident was not checked or changed as frequently as required, with one CNA stating she was the only one working on the hall and another indicating changes were attempted only before lunch and supper. Additionally, the resident's nails were observed to be untrimmed and had a black substance under several nails on multiple occasions, contrary to the facility's nail care policy requiring nails to be kept clean and trimmed. Despite these observations, no staff were seen addressing the resident's nail hygiene during the survey period. The DON confirmed that staff are expected to check and change residents every two hours and maintain clean, trimmed nails, but these standards were not met for this resident.
Delayed Call Light Response and Incontinence Care
Penalty
Summary
Facility staff failed to respond to resident call lights in a timely manner, with observations showing that a resident's call light remained unanswered for at least 10 minutes on multiple occasions. Staff entered the resident's room, turned off the call light, and left without providing the requested assistance, causing the resident to repeatedly activate the call light. Interviews with residents revealed consistent concerns about delayed responses, with some reporting waits of up to an hour and instances where staff turned off call lights without assisting them. The facility's call light system did not record response times, preventing the administrator from obtaining call light reports. Additionally, staff failed to provide timely incontinence care for a resident with mild intellectual disabilities, heart failure, and depression, who required partial to moderate assistance with toileting. Despite care plan instructions to check and assist the resident every two hours, staff did not offer toileting or incontinence care for nearly three hours, resulting in the resident being observed with a heavily saturated brief and visible incontinence products. Staff interviews confirmed that only one CNA was working on the hall at the time, and that care routines were not consistently followed as directed by facility policy.
Staffing Deficiency Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by multiple resident and staff interviews, as well as facility document reviews. Resident interviews revealed that residents felt the facility was understaffed, leading to delays in care. One resident, who is ambulatory, reported having to leave her room to find staff to assist her non-ambulatory roommate. Another resident reported that call lights at night could take over 30 minutes to be answered, and staff expressed feeling overworked. A third resident, who requires assistance with toileting and personal hygiene, reported that staff did not have time to help her apply barrier cream, which was left unused on her nightstand. Staff interviews corroborated the residents' concerns, with several staff members stating that the facility did not have enough staff to adequately care for all residents. Staff reported being unable to take breaks due to insufficient staffing, leading to burnout and high turnover rates. Some staff members were written up for failing to take breaks, despite the lack of coverage to allow for breaks. The facility's staffing coordinator confirmed that the facility often worked short-staffed, with staffing sheets showing that the facility was short-staffed on 13 out of 26 days reviewed. The lack of adequate staffing was linked to an increase in falls and urinary tract infections among residents, as reported by a registered nurse. The facility was on a performance improvement plan to address these issues. The Advanced Registered Nurse Practitioner noted that the facility's layout made it difficult for the limited number of nurses to cover all areas effectively. Overall, the facility's inability to maintain adequate staffing levels resulted in compromised care for residents, as evidenced by the documented delays and omissions in care.
Inadequate Staffing Leads to DON Working the Floor
Penalty
Summary
The facility failed to maintain adequate nursing staff, resulting in the Director of Nursing (DON) and Assistant Director of Nursing (ADON) working the nursing floor on multiple occasions. This occurred despite the facility having a census of 78 residents, which exceeds the regulatory threshold of 60 residents for a DON to serve as a charge nurse. The staffing files from December 2024 revealed that the DON and ADON were scheduled to work the floor on ten occasions. The former DON reported working the floor three times a week or more from November to December 2024, leading to her resignation due to burnout and concerns about her professional license. Interviews with the former DON and the Regional Director of Clinical Services highlighted administrative failures in staffing management. The facility had a staffing contract with an agency, Grapetree, which was not utilized to address the staffing shortages. The facility's job description for the DON allowed for resident care on an as-needed basis but did not specify limits on floor work. The failure to utilize available agency staffing and the lack of clear guidelines contributed to the DON's excessive workload, ultimately leading to her departure.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to serve food within appropriate temperature ranges during a meal service, as observed by surveyors. Multiple residents reported that their meals were often served cold, with one resident expressing concern for others who might not be able to reheat their food. The residents interviewed had intact cognition, as indicated by their BIMS scores. The issue was linked to a malfunctioning steam table and a non-operational plate warmer, which were unable to maintain the required food temperatures during service. The Dietary Cook and Certified Dietary Manager confirmed the problems with the steam table and plate warmer, which had been reported to maintenance but remained unresolved. The steam table was observed to lose significant heat over the course of service, and the plate warmer was not functioning at all. A sample tray prepared for surveyors showed food temperatures below the required levels, with the main dish and vegetables being lukewarm. The facility's policy on food temperature monitoring did not specify target temperatures for serving, contributing to the deficiency.
Inadequate Supervision and Care Planning for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate nursing supervision and care planning for a resident identified as having a high risk for falls. The resident, who had a history of repeated falls, anemia, atrial fibrillation, and severely impaired cognition, experienced multiple falls during their stay. Despite these incidents, the facility did not perform a root cause analysis to determine the reasons for the falls, nor did they update the resident's care plan with appropriate fall interventions. The resident's care plan, initiated upon admission, lacked specific interventions to prevent falls, even after the resident experienced several falls. The facility's documentation revealed that the resident had multiple falls, some resulting in injuries, including a head injury that led to a hospital admission for a brain bleed. The facility's incident reports and progress notes indicated that the resident was often found on the floor, attempting to transfer or move without assistance, and was not consistently using the call light system. Interviews with staff highlighted issues with staffing levels and the completion of incident reports. Some nurses failed to fill out incident reports for each fall, and there was a lack of timely documentation and follow-up on the resident's care plan. The Director of Clinical Services acknowledged the high number of falls and the need for improved incident reporting and care planning. Despite these acknowledgments, the facility did not adequately address the resident's fall risk, leading to repeated incidents and a serious injury.
Failure to Administer Lymphedema Treatment as Ordered
Penalty
Summary
The facility failed to provide treatments as ordered for a resident with severe cognitive impairment and multiple medical conditions, including non-Alzheimer's dementia, atrial fibrillation, congestive heart failure, and chronic lymphedema. The resident was admitted to the facility after a hospitalization for a pubic fracture, with discharge orders that included the use of lymphedema pumps. However, the facility did not implement these orders, as evidenced by the absence of the lymphedema pump in the resident's room and the lack of documentation in the Medication Administration Record (MAR) and Treatment Administration Record (TAR). The Director of Nursing (DON) acknowledged that the lymphedema pump order was not processed accurately upon the resident's admission and subsequent hospital discharge. Despite the presence of the lymphedema pump in the facility, the treatment was not administered as ordered. This oversight was confirmed through staff interviews and record reviews, revealing a failure to accurately review, process, and implement the physician's orders for the resident's care.
Medication Errors and Unattended Medications in LTC Facility
Penalty
Summary
The facility failed to administer medications correctly, resulting in significant medication errors involving two residents. Resident #87, who had intact cognition and multiple medical conditions, accidentally ingested medications intended for another resident, Resident #188. This occurred after a registered nurse left the medication cup unattended on a bedside table. As a result, Resident #87 experienced a severe drop in blood pressure and pulse rate, necessitating emergency room treatment for a beta blocker overdose. The incident was documented in progress notes and a facility incident report, highlighting the nurse's error in leaving medications unsupervised. Additionally, the facility failed to administer the correct dose of a pain medication to Resident #3, who suffered from multiple sclerosis, malnutrition, and chronic pain. The resident's medication administration records revealed that the prescribed Fentanyl patch was not administered on the scheduled date, and subsequent doses were incorrect. The facility's records showed repeated administration of a lower dose than prescribed, without proper documentation or notification to the family and physician. This oversight was acknowledged by the facility administrator as a significant medication error. Observations during a medication administration round revealed further issues with medication management. A registered nurse was seen leaving a medication cart unattended while administering medications to residents, with insulin pens and diabetic supplies left accessible on the cart. Interviews with staff confirmed this practice, despite the facility's policy against leaving medications unattended. The Director of Nursing acknowledged that medications should not have been left unsupervised, indicating a systemic issue with medication administration practices.
Inadequate Staffing Leads to Resident Neglect
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of its residents, as evidenced by multiple observations and interviews. A notable incident involved a resident who was left unsupervised for 56 minutes, despite being on 15-minute checks, which was acknowledged by the Director of Nursing (DON). The facility's documentation inaccurately reflected that the resident was checked every 30 minutes, contradicting the observed evidence. Interviews with residents revealed dissatisfaction with staffing levels, citing long call light response times, missed baths, and inadequate care, particularly during the second and overnight shifts. Staff interviews corroborated the residents' concerns, with several staff members expressing that the facility was understaffed, especially during the evening shift. Certified Medication Aides (CMAs) and Licensed Practical Nurses (LPNs) reported being forced to perform duties outside their roles due to insufficient staffing, which affected their ability to perform their primary responsibilities effectively. Staff also expressed fear of retribution for voicing concerns about staffing levels. The facility's internal documents and interviews with the administration indicated that staffing decisions were based on a facility assessment and feedback from staff, residents, and families. However, the facility had previously reported incidents of residents being left unsupervised, leading to a resident-to-resident sexual encounter that required investigation. The administration acknowledged the need to increase staffing during certain shifts but continued to rely on pool and agency staff as needed.
Deficiencies in Record-Keeping and Resident Monitoring
Penalty
Summary
The facility failed to maintain complete and accurate medical records and did not provide timely access to electronic health records, which hindered the survey process. The Director of Nursing (DON) initially stated that the On-Base software system was used for storing resident documents and promised to set up facility computers for surveyors. However, there were delays in providing access to these records, as the Administrator struggled to make computers available due to security concerns and staff taking computers home. This resulted in surveyors not having access to necessary records, such as advanced directives and PASRR documentation, in a timely manner. During the survey, it was observed that the DON was manually entering information from skin monitoring forms because nurses did not have time to do so, indicating incomplete record-keeping. Additionally, the facility's electronic health records system lacked a PASRR document for a resident, which was later found to have been completed but not included in the resident's records. The facility's entrance conference worksheet also contained incorrect instructions for locating certain documents, further complicating the survey process. Furthermore, a resident was observed wandering the hallway unobserved for 56 minutes, despite their care plan indicating they were on 15-minute checks. The DON later provided resident check forms that inaccurately indicated the resident was checked every 30 minutes. The Health Information Management (HIM) Manager reported issues with indexing and uploading documents into the On-Base system, and a personnel change was made in the HIM department. The facility's policy required medical records to be complete, accurately documented, and readily accessible, but these standards were not met.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of resident transfers to the hospital for five residents, as required by regulations. The deficiency was identified through a review of facility records, staff interviews, and policy review. The residents involved were hospitalized and readmitted to the facility without the required notification to the Ombudsman. Specifically, Resident #29, #9, #57, #50, and #85 were transferred to the hospital, and the facility did not provide proof of notification to the Ombudsman for any of these cases. The facility's policy did not indicate that such notifications were required, contributing to the oversight. Interviews with the facility's Administrator and Social Services Director revealed that the lack of notifications was due to staff not following the ombudsman notification process. This issue was discovered during a mock survey, indicating that notifications had not been completed from at least December 2023 until the end of March 2024. The facility's policy, last reviewed in December 2023, did not include the requirement for ombudsman notifications upon resident discharge or transfer, which may have contributed to the deficiency.
Failure to Investigate and Document Grievances on Missing Cigarettes
Penalty
Summary
The facility failed to adequately investigate and follow up on residents' grievances regarding missing cigarettes. Multiple residents reported their cigarettes were missing, which were supposed to be stored securely at the nurse's station. Despite these reports, the facility's grievance documentation was incomplete, with only one grievance form filled out for a resident's missing cigarettes. This indicates a lack of proper documentation and follow-up on the residents' concerns. Interviews with residents revealed that they had reported their missing cigarettes to various staff members, including the social worker and the Director of Nursing (DON). However, the residents felt that their concerns were not being addressed, and there was a fear that their smoking privileges might be revoked if they continued to voice their grievances. The facility's staff, including CNAs and the social worker, acknowledged that they did not consistently fill out grievance forms when residents reported missing items, further contributing to the lack of resolution. The facility's policy on grievances requires that all grievances be documented and investigated, but this was not adhered to in the case of the missing cigarettes. The Administrator and DON were aware of some reports of missing cigarettes but did not have a comprehensive system in place to track and resolve these issues. The facility's failure to properly document and investigate the grievances led to a deficiency in honoring residents' rights to voice grievances without reprisal and ensuring their concerns were promptly addressed.
Failure to Document and Perform Consistent Wound Care
Penalty
Summary
The facility failed to document assessments, interventions, and treatments for a resident with skin management concerns, specifically pressure ulcers. Resident #64, who had diagnoses including sepsis, diabetes, and multiple pressure ulcers, was not consistently receiving documented wound care as per the treatment administration record (TAR). The TAR from April to June showed multiple instances where treatments were not documented for the resident's left toes, right plantar foot, and left heel. Additionally, there was a lack of documentation regarding the resident's refusal of wound care and the re-approach to offer dressing changes after a missed wound clinic appointment. Interviews with the resident and staff revealed inconsistencies in wound care practices. The resident reported that the dressing changes were not consistently performed, leading to severe drainage from the wounds. Staff A, a registered nurse, acknowledged the resident's noncompliance and stated that they adjusted care times to accommodate the resident's preferences. The Director of Nursing (DON) confirmed that if treatments were not documented, they were considered not done. The facility's policies required systematic assessment and accurate documentation of residents' skin conditions, which were not adhered to in this case.
Failure to Implement Non-Pharmacological Interventions Before Medication
Penalty
Summary
The facility failed to implement non-pharmacological and behavioral interventions before administering antipsychotic medications to a resident, leading to a deficiency in the resident's drug regimen. The resident, who had diagnoses of Parkinson's Disease, dementia, Tourette's syndrome, and repeated falls, was documented to have no hallucinations, delusions, or behaviors according to the Annual Minimum Data Set (MDS) assessment. Despite this, the resident was administered Hydroxyzine and Lorazepam without documented attempts of non-pharmacological interventions prior to medication administration on several occasions. Interviews with staff revealed that while they documented the administration of PRN medications on the Medication Administration Record (MAR), they did not consistently document non-pharmacological interventions in the progress notes. The Director of Nursing (DON) expected staff to document three non-pharmacological interventions in the resident's progress notes whenever a PRN medication was administered. The facility's Psychotropic Medication policy also required that alternative behavioral interventions be evaluated and documented before administering psychotropic medications.
Inaccurate MDS Assessment and PASRR Documentation
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for a resident, identified as Resident #64, who was part of a sample of eighteen residents reviewed. The resident had multiple diagnoses, including adjustment disorder with anxiety, mood disorder, bipolar disorder, and depression. The MDS assessment did not reflect the resident's status as determined by the state level II PASRR process, which identified the resident as having a serious mental illness and recommended specific support services. The care plan for the resident, revised on April 1, 2024, included various diagnoses and behaviors but lacked information about the PASRR completion and the recommended resources. The facility's PASRR policy, revised in November 2022, required that PASRR determinations and evaluation reports be included in the resident's assessment and care plans. However, this was not adhered to in the case of Resident #64. The MDS 3.0 / RAI policy indicated that social services were responsible for completing Section A of the MDS assessment, and the resident's electronic medical record should be reviewed to ensure documentation accuracy. An interview with the Administrator revealed that the social worker filled out Section A of the MDS, but the necessary PASRR information was not incorporated, leading to the deficiency.
Failure to Maintain and Implement PASRR for Residents
Penalty
Summary
The facility failed to maintain a valid Pre-admission Screening and Resident Review (PASRR) for one resident and did not incorporate PASRR service recommendations into another resident's comprehensive care plan. For Resident #37, the Minimum Data Set (MDS) dated 06/11/24 indicated that a Brief Interview for Mental Status (BIMS) could not be completed due to communication difficulties, and the resident had diagnoses including schizophrenia and depression. However, the PASRR dated 10/09/2019 did not include these diagnoses. The Social Services Director acknowledged that the PASRR had not been updated, which was a lapse from previous staff. For Resident #64, the MDS assessments revealed multiple mental health diagnoses and the use of psychotropic medications. Despite this, the care plan lacked documentation of a PASRR completion and the recommended resources. The facility's records did not initially contain a PASRR for this resident, but a PASRR notice dated 7/3/23 was later found, indicating a Level II determination with recommended services such as psychiatric evaluation and therapy. The facility's policy required PASRR findings to be included in the resident's care plan, which was not done in this case.
Failure to Provide Scheduled Baths and Grooming
Penalty
Summary
The facility failed to ensure that residents received their scheduled baths and grooming, as evidenced by the cases of two residents. Resident #50, who has Parkinson's Disease, diabetes, and dementia, required substantial assistance for bathing and personal hygiene. Observations revealed that the resident had uneven and jagged fingernails with brown debris and appeared unshaven. The facility's records showed inconsistencies in documenting the type of bath provided, and there was a lack of documentation for a period between May 21 and June 6. Interviews with staff confirmed that the paper skin sheets used did not indicate the type of bath given, and there was no section for fingernail care. Resident #64, diagnosed with a cerebrovascular accident, dementia, and pressure ulcers, reported not having a bath for ten days, despite being scheduled for baths three times a week. The facility's records showed a lack of documentation for the type of bath provided and missing skin measurements. Interviews with the resident and staff indicated that staffing issues might have contributed to the failure to provide scheduled baths. The facility's bathing policy required documentation of baths in the electronic health record, but the current system did not adequately capture the necessary details.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control techniques were followed during a dressing change for a resident with multiple wounds. The resident, who had diagnoses including sepsis, diabetes, and chronic ulcers, required Enhanced Barrier Precautions. During an observation, a Licensed Practical Nurse (LPN) did not change gloves or sanitize hands appropriately between handling soiled dressings and clean supplies. The LPN opened the resident's room door with a gloved hand, retrieved supplies, and continued the dressing change without performing hand hygiene as required by the facility's infection control policy. The Director of Nursing (DON) confirmed that staff are expected to change gloves and sanitize hands when moving from dirty to clean areas during treatments. The facility's infection control policy mandates glove removal and hand hygiene after handling soiled dressings and before proceeding with treatment. The observed actions of the LPN did not align with these procedures, leading to a deficiency in infection prevention and control practices.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Indianola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Village | 1.3 mi | ★★★★★ | 3 | 0 |
| Westview Of Indianola Care Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Norwalk Nursing And Rehabilitation Center | 10.1 mi | ★★★★★ | 4 | 0 |
| Accura Healthcare Of Carlisle | 10.3 mi | ★★★★★ | 11 | 0 |
| Regency Care Center | 10.9 mi | ★★★★★ | 16 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.