Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Grand Meadows Senior Living & Health Care during CMS and state inspections, most recent first.
Dignified Dining Experience Not Maintained: A resident with moderate cognitive impairment and four other residents were brought to the dining area early and left waiting for breakfast and beverages. They repeatedly asked for coffee, water, and snacks while staff delayed serving drinks; one CNA said beverages were held back so residents would not drink too much and need more brief changes. The DON stated residents should be offered a drink within five minutes, and the facility policy required a dignified existence and resident choice.
A resident with moderate cognitive impairment ended therapy and the Medicare stay, and the record showed a NOMNC signed by the POA, but the facility did not provide the required CMS-10055 ABN when the resident remained in the building. The Administrator was unsure whether the form was completed, and Social Services stated she was not completing ABNs for residents discharged from skilled services or therapy and was unaware they were needed.
A resident with dementia, anxiety, and depression received PRN alprazolam multiple times without documented targeted behaviors or documented non-pharmacological interventions before administration. The care plan did not identify specific behaviors for the antianxiety medication, the eMAR lacked behavior documentation tied to the doses, and the DON stated there was no documentation showing what the medication was treating. Staff described intermittent confusion and occasional anxiety, but the record did not show a psychotropic medication review in the EHR.
Failure to use enhanced barrier precautions occurred for two residents. A resident with an indwelling Foley catheter was observed receiving catheter care without PPE, and no sign or PPE supplies were posted outside the room. Another resident with a Stage 2 pressure ulcer received wound care from the ADON without PPE or enhanced barrier precautions, and there was no sign or PPE supplies outside the room. The care plans for both residents did not direct staff to use enhanced barrier precautions, although staff and the DON stated they should be used for residents with catheters and open wounds.
Failure to screen residents for pneumococcal vaccine eligibility was cited after two residents had incomplete immunization documentation. One resident had severely impaired cognition and records showed influenza and COVID vaccines but no pneumococcal vaccine documentation, while another resident with dementia and diabetes had MDS documentation stating pneumococcal vaccination was up to date despite the immunization form showing only COVID and influenza vaccines; pharmacy documentation indicated the resident qualified for Prevnar 20. The DON stated vaccination history should be entered into the EHR within 48 hours of admission and that both residents should have been offered the pneumococcal vaccine, with declination and education documented if refused.
A resident with intact cognition, ESRD, DM, and HTN developed left ankle pain and a change in transfer ability, including needing a 2-person assist and being unable to bear weight. Staff reported the resident had been complaining of pain for days and needed extra help with transfers, but the nurse progress notes did not document the change or any MD notification. Dialysis later documented severe ankle pain and tenderness, and facility policy required notification for mobility changes and new pain.
The facility failed to properly assess and document two residents after injury events. One resident with intact cognition developed a left ankle fracture after a transfer, but staff notes did not document the earlier pain, inability to bear weight, or a complete post-injury assessment. Another resident with impaired cognition fell in the bathroom, reported severe right leg pain, and was later diagnosed with a right femur fracture, yet the record lacked a full injury assessment such as ROM findings after the fall.
A resident with multiple chronic conditions and intact cognition reported that a nurse entered her room at night without announcing themselves, pulled off her blankets, and attempted to remove her undergarments for a skin assessment, leaving her feeling violated and unsafe. The incident was not communicated effectively among staff, and the same LPN continued to provide care to the resident after the grievance was filed, failing to uphold the resident's rights to dignity and respectful treatment.
The facility was found deficient in food storage and sanitation practices. Expired, unlabeled, and undated food items were observed in storage areas, and the dishwasher sanitizer logs were not maintained. The Certified Dietary Manager acknowledged these issues, noting that the correct test strips might not have been used for chemical concentration checks.
A facility failed to provide ROM services to a resident with musculoskeletal issues and reduced mobility. Despite the resident's intact cognition and care plan focus on pain management, no ROM treatment was included. Staff interviews revealed the absence of a formal restorative program, and the resident was not asked to participate in ROM activities, preferring to stay in his room.
A facility failed to provide trauma-informed care for a resident with PTSD, anxiety, adjustment disorder, and depression. The resident's care plan lacked necessary details about mental health triggers and interventions. Staff interviews revealed confusion about responsibilities for managing the resident's mental health needs, and observations showed mood and behavioral issues without documented responses.
A facility failed to ensure psychotropic medications were used only for documented conditions in a resident with dementia, anxiety, and depression. The care plan did not address all medications or include triggers for PRN use. Observations showed signs of anxiety, but there was no documentation of behavior monitoring or non-pharmacological interventions. Staff interviews revealed that behavior monitoring should be documented, but this was not done.
The facility did not secure and supervise access to hot steam table surfaces, allowing eight cognitively impaired and independently mobile residents to access these areas. Observations showed that the steam tables were accessible without consistent staff supervision, and the barrier gate to the kitchenette was broken. One resident with severely impaired cognition and at risk for elopement was able to wander freely, including areas with hot steam tables. This lack of supervision and broken barrier gate posed significant risks to the residents' health and safety.
The facility failed to maintain sanitary conditions in the kitchen and household kitchenettes, with undated opened foods, food particles, and mold observed. Staff did not follow proper glove usage protocols during meal service, affecting multiple residents. Interviews revealed a lack of clear responsibility and training for cleaning and food handling.
The facility failed to keep garbage cans covered near food preparation surfaces, compromising a sanitary cooking environment. Observations revealed trash cans without lids and containing trash, with one instance of a soiled plastic sheet overflowing. The Dietary Services Manager confirmed that trash cans should be covered when not in use, as per the facility's Pest Control policy.
A resident, who is cognitively intact and dependent on assistance for toileting, reported that an LPN removed his call light, leaving him unable to call for help and soaked in urine until the next morning. The incident was not documented, and the LPN was subsequently made a Do Not Return due to her behavior.
A resident reported that a staff member removed his call light, leaving him without assistance and resulting in him being soaked in urine. The facility failed to document the incident, report it promptly, or conduct a thorough investigation as required by policy.
The facility failed to ensure an effective QAPI process to address previously identified quality deficiencies, resulting in repeated deficiencies for accidents and hazards. The Registered Nurse Consultant was unaware if the previous team worked on the citation, and the Administrator confirmed the concern related to the pattern of deficiencies. The facility's QAPI Plan included systems to monitor care and utilize data from various sources.
Dignified Dining Experience Not Maintained
Penalty
Summary
The facility failed to ensure a dignified dining experience for Resident #13 and four other residents when they were brought to the dining area early and left waiting for breakfast and beverages. Resident #13’s quarterly MDS showed a BIMS score of 10 out of 15, indicating moderate cognitive impairment, with diagnoses of unspecified dementia without behavioral disturbance and diabetes mellitus. On 3/26/26, residents were observed at the dining table beginning around 6:45 AM, and by 7:00 AM five residents were seated and repeatedly asking for drinks, snacks, and breakfast. Resident #13 repeatedly asked for coffee and was told by Staff F that it would be a little bit, while other residents asked for water or a snack and were given similar responses. During the observation, Staff K prepared drinks and placed them on a tray in the kitchenette but did not serve them to the residents, stating the beverages were being held until closer to meal time so residents would not drink them too soon and need more bathroom trips and brief changes. Resident #13 stated the residents were brought out too early and had to sit and wait a long time, and said there was no reason they could not have something to drink, including water. Staff L stated residents are typically brought out closer to meal time and that if they were brought out that early, they should have been offered something to drink and a snack. Staff B stated residents are usually provided drinks while they wait, while the DON said residents should be offered a drink within five minutes and that 6:30 AM was too early unless requested by the resident. The facility policy stated residents have the right to a dignified existence, self-determination, and autonomy and choice in daily life and care.
Failure to Issue ABN When Skilled Services Ended
Penalty
Summary
The facility failed to provide Resident #20 with form CMS-10055, the Advance Beneficiary Notice of Non-Coverage, when the resident ended therapy services and planned to remain in the building after the end of the Medicare stay. Resident #20’s MDS showed admission to the facility and a BIMS score of 11/15, indicating moderate cognitive impairment. The record contained a NOMNC (CMS 10123) dated 11/07/2025 documenting the end of skilled services, and it was signed by the resident’s power of attorney on 11/05/2025, but the facility did not provide a CMS-10055. During interviews, the Administrator stated he was unable to say whether the facility completed the CMS-10055 for discharged residents and said social services completed them, while the Social Services staff stated she was not completing the CMS-10055 for residents discharged from skilled services or therapy who remained in the facility and was not aware it was needed. The Medicare Claims Processing Manual states the ABN form CMS 10055 is used by a SNF to transfer financial liability to an original Medicare beneficiary for items or services Medicare is expected to deny payment for.
PRN antianxiety medication given without documented behaviors or non-pharmacological interventions
Penalty
Summary
The facility failed to document targeted behaviors and to provide documented non-pharmacological interventions before administering an as needed antianxiety medication to a resident with non-Alzheimer's dementia, anxiety, and depression. The resident's MDS showed moderate cognitive impairment, no depression on PHQ-2, and no behavioral symptoms, hallucinations, or delusions during the look-back period. The care plan addressed depression and anxiety related to dementia, but it did not identify targeted behaviors for the PRN antianxiety medication. The resident received alprazolam 0.5 mg every six hours as needed beginning after the daughter reported the resident had been calling family members overnight and said the resident had used alprazolam before admission. The medication was ordered for 14 days, then renewed, and the MAR showed eight doses were given during the first order period and seven more during the second. Review of the eMAR notes found no documentation of behaviors or non-pharmacological interventions before any of the PRN doses were administered. Daily skilled nursing notes documented intermittent confusion, yelling at times, pleasant confusion, and moderate to severe confusion, and staff interviews described occasional anxiety, rolling back and forth in the wheelchair, and agitation related to environmental factors. Staff also stated that talking with the resident or moving her out of her room would usually calm her down. The DON stated the facility expected staff to document behaviors and detailed progress notes, including contributing factors and interventions, before giving PRN psychotropic medications, and also stated there were no targeted behaviors on the care plan and no documentation showing what the alprazolam was treating. No psychoactive/psychotropic medication review was located in the resident's electronic health record.
Failure to Use Enhanced Barrier Precautions for Residents with Catheter and Wound
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility failed to use enhanced barrier precautions for two residents with conditions identified in the facility policy. Resident #7 had an indwelling Foley catheter per the MDS and care plan, and the care plan directed staff to position the catheter bag and tubing below the bladder and away from the entrance room door, but it did not direct staff to use enhanced barrier precautions. During observation, a CNA emptied the Foley catheter in the resident’s room without using any personal protective equipment, and there were no supplies outside the room or sign posted on the door to indicate enhanced barrier precautions. Resident #11 had a Stage 2 pressure ulcer to the coccyx per the MDS and care plan, but the care plan also failed to direct staff to use enhanced barrier precautions. During observation, the ADON performed wound care to the resident’s buttocks and completed the dressing change without donning personal protective equipment or using enhanced barrier precautions. There was no sign outside the resident’s door and no PPE supplies available. Staff interviews indicated enhanced barrier precautions should be used for residents with open wounds, catheters, and other specified conditions, and the DON stated signs on the door would identify residents on enhanced barrier precautions.
Failure to Screen Residents for Pneumococcal Vaccine Eligibility
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations was cited after the facility failed to screen residents for eligibility for the pneumococcal vaccine for 2 of 5 residents reviewed. Resident #7 had severely impaired cognition for daily decision making on the admission MDS, which documented that the resident received an influenza vaccine outside the facility, was not up to date with pneumococcal vaccination, and was not offered a pneumococcal vaccine. The Immunization Consent Forms dated 10/24/24 and 10/16/25 documented receipt of COVID and influenza vaccines, but there was no documentation of a pneumococcal vaccine. Resident #13 had diagnoses including unspecified dementia without behavioral disturbance and diabetes mellitus, with a BIMS score of 10 out of 15 indicating moderate impairment. The quarterly MDS documented that the resident was up to date on pneumococcal vaccination, but the Immunization Consent Form dated 11/13/25 documented only COVID and influenza vaccines, with no pneumococcal vaccine documentation. Documentation from the pharmacist dated 1/13/26 revealed the resident qualified for Prevnar 20. During interview, the DON and Infection Control Preventionist stated resident vaccination history should be entered into the EHR within 48 hours of admission and that both residents should have been offered the pneumococcal vaccine, with declination and education documented if refused; the DON also stated there had been significant staff turnover and no staff assigned to entering vaccinations.
Failure to Notify Physician of Transfer Change and Left Ankle Pain
Penalty
Summary
The facility failed to notify the physician of a change in Resident #25’s transfer status and left ankle pain. Resident #25 had intact cognition, required supervision or touching assistance for sit-to-stand and toilet transfers, and had diagnoses including hypertension, end stage renal disease, and diabetes. Facility nurse progress notes from 2/13/26 through 2/15/26 did not document left ankle pain, a change in transfer status, inability to bear weight, or any physician notification. Dialysis documentation on 2/16/26 noted the resident arrived with a complaint of significant left ankle pain and inability to stand on it, and an APRN documented medial and lateral malleolar pain that was exquisitely tender and denied trauma. Staff statements indicated the resident had been requesting increased assistance with transfers and reporting pain before the dialysis visit. An LPN stated the resident requested a 2-person assist because she could not bear weight on her left leg and later requested pain medication. A CNA reported the resident said it was hard to put weight on her left leg and that the nurse knew about the situation because extra help was needed for transfers. Another LPN said the resident had been complaining for a couple of days, had a sore on her leg, and was not transferring normally. Facility staff and the DON stated that changes in transfer status and complaints of pain should be reported to the physician, and the facility policy required notification of the resident’s family or representative and medical practitioner for mobility changes and unusual or new pain.
Failure to assess and document injuries after falls and transfer-related events
Penalty
Summary
The facility failed to assess and intervene for two residents with injuries. One resident with intact cognition, end stage renal disease, diabetes, and hypertension developed left ankle pain associated with a tibial fracture after a transfer event. The record showed the resident complained of left ankle pain and inability to stand on the leg during dialysis, and staff statements described the resident reporting that her leg was caught between staff members’ legs and her ankle twisted during a transfer. However, the facility’s progress notes from the days before the fracture did not document left ankle pain, a change in transfer status, or an assessment of the lower extremity, and the notes after the fracture did not include a pain assessment or circulation checks. Staff statements indicated the resident had complained of pain and difficulty bearing weight before the fracture was identified, but this was not documented in the nurse progress notes. A second resident with moderately impaired cognition, renal dialysis dependence, heart failure, and respiratory failure had a fall in the bathroom and later was found to have a right femur fracture. The incident documentation and health status notes described the resident losing footing, falling to the floor, and reporting right leg pain rated as high as 8 to 10. The resident was assisted back to bed, received Tylenol, and had vital signs and neurological checks documented as intact, but the notes did not include a range of motion assessment or documentation of an attempt to evaluate the injury further. The resident later went to dialysis and then to the emergency room, where an acute right femur fracture was identified. Interviews and additional records showed staff were aware of pain and changes in mobility, but the documentation did not reflect a complete assessment at the time of the fall or after the change in condition. For the resident with the ankle fracture, staff statements described complaints of pain and inability to bear weight during transfers before the fracture was confirmed. For the resident with the femur fracture, staff and dialysis records described severe pain, inability to bear weight, and a later hospital diagnosis of fracture, while the facility’s fall review attributed the event to weakness and recent infections. The facility policy required documentation of the resident’s current status related to the change in condition and charting each shift for 72 hours, but the records reviewed did not show those assessments for the injuries described.
Failure to Ensure Resident Dignity and Respect During Nighttime Care
Penalty
Summary
Staff failed to treat a cognitively intact resident with dignity and respect during care, as evidenced by an incident that occurred during the night following the resident's admission after a week-long hospitalization. The resident, who had diagnoses including Chronic Kidney Disease, Osteoarthritis, and Sjogren Syndrome, reported that while she was sleeping, a nurse entered her dark room without announcing themselves, pulled her blankets off, and attempted to remove her undergarments for a skin assessment. The resident was startled, attempted to resist, and ultimately had her underwear ripped during the encounter. The staff member did not provide any explanation or attempt to awaken the resident prior to initiating the assessment, which left the resident feeling violated and unsafe. The resident reported the incident to the Social Services (SS) designee during a routine post-admission assessment. She described feeling so unsafe after the event that she placed her walker in front of her door for security and experienced incontinence due to fear. The resident also expressed confusion and distress over the lack of communication and the manner in which the assessment was conducted. Despite being told by the SS designee that the staff member would not have further contact with her, the same nurse subsequently administered medications to the resident on multiple occasions after the grievance was filed. Interviews with staff confirmed that the incident involved a night shift nurse performing a skin assessment without proper communication or consent, and that the resident's concerns about exposure and feeling violated were not fully relayed or addressed by staff. The facility's records and interviews corroborated that the resident's rights to dignity, respect, and self-determination were not upheld during the care provided, as required by the facility's Resident Rights policy.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional guidelines for food storage and sanitation during a kitchen observation. The surveyor noted expired, unlabeled, and undated food items in both dry storage and the refrigerator. Specifically, there were 16 boxes of baking soda that had expired, sliced cheese wrapped without a label or open date, and an opened, undated container of cottage cheese. Additionally, several clear plastic bins containing various food items were either undated or dated beyond the facility's policy of a 7-day storage limit. The Certified Dietary Manager (CDM), who had recently taken over the kitchen, acknowledged these issues and mentioned that she had already discussed labeling and dating with the staff. Furthermore, the facility did not maintain proper records for dishwasher sanitizer logs, and the sanitizer sink did not register the chemical content as required. The CDM admitted that the test strips used might not have been the correct ones and was unable to provide additional documentation for dishwasher chemical testing. The facility's policies on dish machine operation and food storage were not followed, as they required proper labeling, dating, and chemical concentration checks, which were not adhered to during the surveyor's observation.
Failure to Provide Range of Motion Services
Penalty
Summary
The facility failed to provide range of motion (ROM) services to maintain or improve the functioning of a resident, identified as Resident #11, who was reviewed during a survey. The resident had intact cognition and was diagnosed with musculoskeletal symptoms, reduced mobility, and spasmodic torticollis. The Minimum Data Set (MDS) indicated that the resident did not receive active or passive ROM restorative nursing in the prior seven days. The resident's care plan, initiated on March 29, 2024, did not include treatment and services to increase or prevent further decrease in ROM, despite having a focus area for pain that included an intervention to observe and report a decrease in functional abilities or ROM. Interviews with staff revealed that the facility did not have a formal restorative program or a staff member specifically designated for restorative therapy. The Occupational Therapy (OT) and Physical Therapy (PT) discharge summaries indicated that the resident had participated in therapy but no restorative or functional maintenance program was established. The resident expressed a preference to stay in his room and was not asked to participate in ROM activities. The facility's policy stated that restorative nursing should promote the resident's ability to live as independently and safely as possible, but this was not implemented for the resident in question.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, anxiety, adjustment disorder, and depression. Upon admission, the resident was not assessed for potential triggers that could cause re-traumatization. The resident's care plan did not address anxiety, adjustment disorder, or PTSD, nor did it include mental health triggers, medications, examples of side effects to watch for, behaviors, or non-pharmacological interventions to address these diagnoses. The resident expressed feelings of anxiety and depression related to her situation and changes in health, but there was no evidence that staff had inquired about her mental health triggers or how to manage them. Staff interviews revealed a lack of communication and responsibility regarding the resident's mental health needs. The MDS Coordinator admitted to not including the necessary information in the care plan, and the social worker and other staff were unclear about who was responsible for identifying and managing the resident's mental health triggers. Observations and progress notes indicated that the resident exhibited mood and behavioral issues, such as yelling and crying, but staff did not document the reasons for these behaviors or their responses to them.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications were used only to treat documented conditions for a resident with non-Alzheimer's dementia, anxiety disorder, and depression. The resident's care plan included interventions for administering Olanzapine and Buspirone, but did not address the use of Alprazolam, Escitalopram, and Mirtazapine. Additionally, the care plan lacked triggers for PRN medications and did not follow the directed protocol for monitoring depressive and anxious behaviors. The facility did not respond to the pharmacist's request to document resident behaviors or implement non-pharmacological interventions to help reduce anxiety. Observations revealed that the resident exhibited signs of anxiety, such as crossing and uncrossing legs, bouncing a leg, and walking without a walker. Despite these behaviors, there was no documentation of behavior monitoring or non-pharmacological interventions in the resident's progress notes. Interviews with staff indicated that behavior monitoring should be included in the care plan and documented in progress notes, but this was not done. The facility's policy required the consultant pharmacist to have access to relevant health records to make professional judgments, but the necessary documentation was not provided.
Inadequate Supervision and Access Control to Hazardous Areas
Penalty
Summary
The facility failed to secure and supervise access to hot steam table surfaces, allowing eight cognitively impaired and independently mobile residents to access the areas holding the steam tables. This failure resulted in an Immediate Jeopardy situation for the residents' health, safety, and security. Observations revealed that the steam tables were accessible to residents, with staff not consistently present to supervise the area. Additionally, the barrier gate to the kitchenette was broken, further contributing to the residents' ability to access the hazardous area. One specific resident, identified as Resident #23, had severely impaired cognition and was identified as independent with ambulation and transfer with an assistive device. Despite being at risk for elopement, Resident #23 was able to wander freely in the facility, including areas with hot steam tables. The facility's failure to address the broken barrier gate and lack of supervision in the kitchenette area posed a significant risk to Resident #23 and other residents who were also observed wandering unsupervised in the dining room and halls.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitary conditions in the kitchen and household kitchenettes, as well as during meal service. Observations revealed undated opened foods, food particles and splatters in refrigerators and freezers, and a moldy calcified water spot under the water dispenser. Additionally, the ice machine had streaks running down the lip of the ice chute, and food matter was found on the floor by the heating unit and the two-compartment sink near the refrigerator. Follow-up observations confirmed that no cleaning or dating of food items had been conducted since the initial findings. During meal service, staff failed to follow proper glove usage protocols, touching various surfaces and then handling food without changing gloves. This occurred multiple times, affecting numerous residents. Room trays were transported with uncovered water and coffee, and serving scoops were placed in food containers with the handles directly touching the food. Additionally, sticky substances were observed coating the floors in both households. Interviews with staff revealed a lack of clear responsibility and training for cleaning and food handling. Staff reported that dietary staff were expected to clean equipment and kitchen areas, but household staff often ended up doing it without proper instruction or schedules. The Director of Nursing (DON) and other staff members confirmed that there was no consistent schedule for cleaning tasks, and that training on food safety and sanitation was not adequately provided. Facility policies were reviewed and found to be undated, with expectations for cleanliness and food handling not being met by the staff.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to keep garbage cans covered near food preparation surfaces, compromising a sanitary cooking environment. During multiple observations, trash cans next to the meat slicer and food preparation counter were found without lids and containing trash. On one occasion, a soiled plastic sheet was overflowing out of a trash can. The Dietary Services Manager stated that trash cans should be covered when not in use and that facility policies should be followed. The facility's Pest Control policy requires garbage containers to be tightly covered, clean, and in good condition, with spills cleaned up immediately and containers regularly sanitized.
Neglect of Resident Due to Call Light Removal
Penalty
Summary
The facility failed to prevent neglect of a resident who reported abuse. Resident #35, who is cognitively intact with a BIMS score of 15, dependent on assistance for toilet transfers and hygiene, and blind in the right eye, reported that a staff member became frustrated with his frequent use of the call light. The staff member told him to use his depend and then removed the call light, placing it out of his reach. As a result, Resident #35 was unable to call for assistance and was left soaked in urine until the next morning, causing him significant distress and making him feel demeaned and neglected. The incident was not documented in the Nurse Progress Notes, and the staff member involved, an LPN agency staff, was subsequently made a Do Not Return (DNR) due to her behavior. The facility's policy on Dependent Adult Abuse Prevention defines neglect as the failure to provide necessary care to avoid physical harm, mental anguish, or emotional distress. The Scheduling Coordinator/Recruiter confirmed that the LPN was made a DNR due to being rude to other residents and taking away a call light from a resident, as directed by the Director of Nursing and the Administrator.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of abuse involving a resident who was cognitively intact and dependent on staff for toileting due to an amputation and blindness in one eye. The resident reported that a staff member became frustrated with his frequent use of the call light, removed it from his reach, and left him without assistance, resulting in the resident being soaked in urine by the time staff attended to him the next day. The incident was not documented in the resident's electronic health record, and the facility administrator only reported the incident to the staffing agency and later to the state agency without conducting an internal investigation or interviewing staff involved. The facility's policy required immediate reporting of such incidents to the Department of Inspections and Appeals (DIA) within 2 hours and a comprehensive investigation within 5 working days. However, the administrator failed to follow these procedures, only summarizing the wife's report to the state agency and not conducting any follow-up investigation. The nurse consultant acknowledged the failure to report and investigate the incident properly, stating that the alleged perpetrator should have been separated from residents and the incident reported to DIA promptly.
Repeated Deficiencies in Accidents and Hazards
Penalty
Summary
The facility failed to ensure an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated deficiencies cited on the current survey and cited in previous surveys. The CMS 2567 forms dated 9/13/22, 2/28/23, and 9/14/23 reflected deficiencies identified for accidents and hazards. During the current recertification, complaint, and facility-reported incident survey dated 4/23/23, the team identified the same deficiency, Accident and Hazards (F689). On 4/22/24, the Registered Nurse Consultant (RNC) reported working on the accidents and hazards in the building but was unaware if the previous team worked on that citation. On 4/23/24, the Administrator confirmed the concern related to the pattern of deficiencies at F689. The facility provided a QAPI Plan dated 12/1/22, which included feedback, data systems, and monitoring, stating the facility would put systems in place to monitor care and utilize data from various sources, including tracking, investigating, and monitoring adverse events every time they occur, and actions implemented through the Plan, Do, Study, Act (PDSA) cycle of improvement to prevent recurrence.
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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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Nursing homes near Asbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hawkeye Care Center Dubuque | 0.9 mi | ★★★★★ | 6 | 0 |
| Ennoble Nursing And Rehab | 1.9 mi | ★★★★★ | 0 | 0 |
| Luther Manor At Hillcrest | 2 mi | ★★★★★ | 18 | 0 |
| Dubuque Specialty Care | 2.3 mi | ★★★★★ | 0 | 0 |
| Harmony Dubuque | 4.3 mi | ★★★★★ | 10 | 0 |
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