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 Iowa City Rehab & Health Care during CMS and state inspections, most recent first.
Failure to inform residents about psychotropic meds: The facility did not document consent, education on risks/benefits, or discussion of alternative tx before starting or increasing psychotropic medications for several residents. Records showed orders for antidepressants, antianxiety meds, antipsychotics, hypnotics, and related dose changes, but no progress notes or assessments confirmed that residents or their representatives were informed in advance as required by facility policy.
Worn dining chairs were observed in the entrance area and North DR, with faded varnish, loose arms, and cracked or peeling vinyl upholstery. A resident with COPD and DM reported that housekeeping only swept and cleaned toilets, not tables, and sticky rings were observed on the table in the resident’s room; staff also reported there was no current housekeeping manager amid budget cuts and staff changes.
The facility failed to complete QAA activities to gather feedback, use data, and conduct structured analysis of problems affecting quality of care, quality of life, and resident safety. Review of QAPI meeting documentation, policy, and staff interview showed no documentation of QA activities focused on restorative services and staffing, despite the QAPI/QAA plan stating that survey findings and other data would be used for systematic action and analysis. Prior CMS and current survey findings identified related concerns.
The facility failed to carry out QAA activities by not documenting required quarterly QA meetings. Review of QAPI attendance logs showed a gap in meeting documentation for several months, even though the QAPI and QAA Plan stated that PIPs would be reviewed at least quarterly. The Administrator stated that monthly QA meetings were conducted, but some months in the last year were missed.
Failure to honor a resident’s request for staff masking. A resident with COPD and respiratory failure, intact cognition, and a care plan noting infection risk and a preference for staff to wear a mask reported that staff did not consistently comply with the request despite a sign on the door. An RN was observed leaving the room without a mask and said the sign was only for strangers, while an LPN later stated the resident wanted masks worn for her protection. The Administrator acknowledged the resident’s preference should be supported and that masks were available.
A facility failed to complete a criminal background check before hiring 1 of 2 newly hired employees. A CMA's personnel file lacked documentation of the required check, and the Interim Administrator stated there was no other employee file documentation. The DON stated criminal background checks should be done before hire, and the facility policy required criminal record checks on all prospective employees.
The facility failed to provide bed hold information for two residents who were hospitalized and failed to notify the ombudsman for one resident’s hospitalizations. One resident had ESRD, blindness, and breathing abnormalities with intact cognition, and the record lacked documentation of bed hold notices and ombudsman notification for multiple ER transfers. For another resident, the EHR documented several hospital leaves and transfers, but bed hold documentation was only found for one hospitalization, with no record for the others.
Failure to complete a Significant Change MDS after a resident enrolled in hospice. The Census Line showed hospice enrollment, but the MDS section still listed the assessment as in process and incomplete. The MDS coordinator said she had not been informed of the hospice admission and had not set up the assessment. The RAI Manual and facility policy both required a Significant Change assessment when a terminally ill resident enrolls in hospice.
A facility failed to ensure adequate bathing assistance for two residents who required help with ADLs. One resident with hemiplegia, stroke, and bipolar disorder reported going about a week between showers, while another resident with HF, DM, and seizures reported going two weeks between showers and being told there were only two aides. Shower logs showed missed or limited bathing documentation, and staff said showers were missed because of staffing issues.
Failure to Provide Restorative Walking Program: A resident with hemiplegia, stroke, and bipolar disorder had intact cognition and was able to walk with PT using assistive devices, but staff did not continue walking with her after therapy ended. The record lacked documentation of staff-assisted walking after PT discharge, and staff stated the restorative program was new, had not been in place before, and they had not received direction to walk with the resident.
A resident with ESRD, blindness, and breathing abnormalities had a care plan and MAR directions for dialysis access monitoring, but staff did not document access site assessments on non-dialysis days. The MAR lacked Sunday assessments, and staff including the ADON, RN, LPN, and DON stated the site was checked on dialysis days but not on non-dialysis days, despite the facility policy calling for the nurse to check the access site every shift.
The facility failed to verify a newly hired CMA's certification before hire. The New Hire List and Roster listed the CMA as hired, but there was no documentation of certification verification. The facility policy stated that all personnel certifications would be verified, and the DON stated that CNA verification and criminal background checks should be done before hire.
A facility failed to ensure prescribed stock medications were available for two residents. One resident had repeated missed doses of MiraLax and Lidocaine patches, and another resident had multiple missed Lidocaine patch doses with MAR codes showing the medication was not available. The resident reported going several days without patches and staff confirmed the facility frequently ran out of stock meds, including lidocaine patches, with replacement sometimes delayed until the following week.
Call lights were not functioning or were out of reach for two residents. One resident with intact cognition reported his call light had stopped working weeks earlier, and staff testing showed it was intermittent and had not been reported until later. Another resident with hemiplegia, stroke, and bipolar disorder was observed in bed with the call light on the floor out of reach, and staff only provided it after the issue was identified.
The facility failed to ensure that 1 of 5 staff files reviewed had current DAA Mandatory Reporter's Training. A CMA hired in the facility did not have documentation of completing the required 2-hour abuse reporting training within 6 months of hire, and the Interim Administrator stated he had no other employee file documentation and was aware of concerns with the files.
A resident with paraplegia, dementia, malnutrition, and continuous PEG tube feeding at 75 mL/hr was repeatedly observed lying in bed with the head of the bed flat and without the ordered abdominal binder, despite physician orders for continuous tube feeding and binder use at all times. Staff allowed the feeding to run while the resident lay flat and while PEG tubing was under tension after a self-transfer from wheelchair to bed, and multiple staff entries into the room occurred without correcting the bed position or applying the binder. In interviews, staff acknowledged that the head of the bed should be elevated during continuous tube feeding and that the binder was needed to prevent the resident from pulling out the PEG tube, while the facility’s feeding tube policy lacked specific guidance on required head-of-bed positioning.
A resident with Alzheimer’s disease, diabetes, thyroid disease, and atrial fibrillation was admitted on time-limited hospital discharge medication orders that were written for 20 days. MAR review showed that numerous routine medications, including anticoagulants, cardiac, psychiatric, endocrine, and respiratory drugs, were administered only through the 28th of the month and then not scheduled or given for the next three days, and many were not scheduled at all the following month. An ED note documented that the resident’s daughter reported medications had been stopped without explanation and that the pharmacy indicated discharge meds had not been renewed. RNs and the NP gave conflicting accounts of who was responsible for renewing these orders, there was no documentation that nurses notified the provider about the 20-day limits, and the facility’s medication reconciliation and reordering policies requiring systematic review and timely reordering were not followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment, with observations of broken hygienic equipment, rusted heating/AC units, and significant dirt and grime buildup in multiple resident rooms. Staff confirmed ongoing issues with cleaning and equipment repair, and facility policy on routine cleaning and disinfection was not consistently followed.
Two residents did not receive prescribed medications as ordered due to staff failing to order and administer them in a timely manner. One resident missed multiple doses of a narcotic pain medication, while another experienced a delay in starting new medications for respiratory symptoms. These actions were not in accordance with facility policy requiring timely and accurate medication administration.
Three residents with conditions such as COPD, cerebral palsy, and morbid obesity were not provided with restorative nursing programs despite care plans indicating the need for exercise and therapy interventions. Residents expressed a desire to use exercise equipment to maintain or improve mobility, but were denied due to lack of staff and absence of a restorative program, as confirmed by staff and administration.
The facility did not provide enough nursing staff to meet resident needs, resulting in delayed responses to call lights and residents waiting extended periods for assistance. Staff and residents reported that low staffing, especially on one hall, led to frequent delays in care and unmet needs, contrary to facility policy requiring timely response.
Two residents experienced deficiencies in care when staff failed to follow physician orders for wound care, medication administration, and dietary management. Wound dressings were not changed as prescribed, medications were not administered according to schedule, and significant weight loss was not reported to the physician. Wound assessments lacked essential details, and documentation did not accurately reflect the care provided. Staff interviews confirmed inconsistencies in following orders and documentation practices.
A resident with intact cognition and multiple diagnoses was observed with a diuretic pill at bedside, which staff confirmed was taken only after checking back. The clinical record lacked documentation that the resident was assessed as safe to self-administer medications, contrary to facility policy requiring physician and care team determination before allowing self-administration.
A resident who was cognitively intact and discharged home from skilled nursing services under Medicare Part A did not receive the required Notice of Medicare Non-Coverage (NOMNC) due to a lack of staff training and absence of a facility policy, resulting in the resident not being informed of their appeal rights.
A resident with hemiplegia, stroke history, and dysphagia was repeatedly observed eating in bed with the head of the bed elevated less than 15 degrees, despite staff acknowledging the need for upright positioning to prevent choking. Staff practices were inconsistent, and the facility lacked a policy on safe meal positioning.
The facility did not implement a bladder training program or other interventions for a resident with reversible urinary incontinence, despite assessments indicating the resident could participate. Additionally, catheter tubing and drainage bags for another resident with a suprapubic catheter were repeatedly observed resting on or dragging along the floor, contrary to facility policy and infection control standards.
A resident with diabetes received insulin from an LPN who did not prime the insulin pen before injection, despite manufacturer instructions and facility expectations to do so. The LPN believed priming was only needed for the first use, leading to a significant medication error as the pen was not primed before administering the prescribed dose.
Staff were observed using nicotine vape pens in offices near the dining room and during activities with residents present, despite a facility policy restricting tobacco use to designated areas. Multiple staff confirmed these incidents, which occurred in violation of the facility's Tobacco Policy and in the presence of residents.
A resident with a seizure disorder and intact cognition repeatedly reported multiple daily seizures to staff, but nursing staff did not consistently assess, document, or notify the neurology provider as required by physician orders and facility policy. Staff interviews confirmed that although the resident's reports were communicated among staff, the necessary notifications and documentation were not completed.
The facility did not have an Infection Prevention Specialist or Infection Control Nurse, as required for effective infection control. The Administrator reported that the Assistant Director of Nurses, who previously handled infection control, left the facility a month ago, and a replacement was only found recently.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling devices, leading to a deficiency in infection control. Staff did not use gowns during high-contact activities, and rooms lacked appropriate signage and PPE. Interviews revealed a lack of staff education on EBP, exacerbated by the recent loss of key infection control personnel.
The facility failed to provide adequate staffing, resulting in delayed call light responses. On a morning, four call lights were observed blinking in the East Hall, with only one LPN present due to an aide's late arrival. This led to response times as long as 39 minutes. Interviews revealed that residents had previously complained about call light delays, and a call light audit confirmed the issue.
The facility failed to ensure proper personal hygiene in the kitchen when two male dietary employees with facial hair did not wear beard guards, as required by the facility's policy. The Dietary Manager acknowledged the oversight, noting that beard guards were available and had been used in the past.
The facility failed to ensure proper medication administration for two residents with moderate cognitive impairment. Medications were left unattended in residents' rooms without orders for self-administration, contrary to facility policy requiring staff to remain with residents until medications are taken.
A resident with severe cognitive impairment suffered burns from spilled coffee due to inadequate supervision and lack of assistive devices. Another resident, with impaired decision-making, was allowed to smoke independently, violating the facility's smoking policy. The facility failed to implement necessary interventions and ensure adherence to safety measures, resulting in unsafe conditions.
Two residents in a facility were observed with urinary drainage bags in contact with the floor, risking cross-contamination and UTIs. Despite care plans and staff expectations to keep bags off the floor, observations showed non-compliance. The facility lacked specific policies for handling urinary drainage bags, relying on a general infection control policy.
A resident on hospice care, requiring substantial assistance for eating, was observed being assisted by a CNA who used her personal cell phone during the meal, violating facility policy. The CNA attempted to hide her phone when noticed by a surveyor, claiming a family emergency. This action compromised the resident's dignity, as the facility's policies emphasize maintaining a dignified existence and restrict personal phone use to breaks.
Failure to Inform Residents About Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments when psychotropic medications were initiated or increased. Based on clinical record review, staff interview, and policy review, 4 of 5 residents reviewed for unnecessary medications did not have documentation that they were educated about the risks and benefits of psychotropic medications or that alternative treatment options were offered before the medications were given. Resident #4 had diagnoses including non-Alzheimer's dementia, depression, and schizophrenia, with severe cognitive impairment documented on the MDS. The MAR showed sertraline was started and increased, but the EHR did not show consent obtained before administration. No progress notes or assessments documented education about side effects, risk versus benefits, or alternative treatments. A care conference was held, but no resident representative was recorded as present, and the social work summary only documented increased depressive symptoms and medication changes. Resident #6 had diagnoses including non-Alzheimer's dementia and anxiety disorder, with moderate cognitive impairment documented on the MDS. The MAR showed orders for fluvoxamine, lorazepam, and seroquel, but the EHR did not show consent obtained before administration. Resident #7 had depression and insomnia with intact cognition, and the MAR showed a new order for zaleplon, but there was no consent, education, or documentation of alternative treatments. Resident #43 had diagnoses including non-Alzheimer's dementia, anxiety, and depression with intact cognition, and the MAR showed multiple increases and new orders for mirtazapine, aripiprazole, ambien, and trazodone; the EHR did not show consent obtained for any of these medications, and no progress notes or assessments documented education about risks, benefits, or alternatives. The DON stated the nurse practitioner often provided education when new psychotropic medications were ordered, and the facility policy required residents or representatives to be informed in advance of risks, benefits, and alternatives and to have the right to accept or decline.
Worn Dining Furniture and Unclean Resident Room
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable interior in the main entrance and North dining room areas. On observation, two wooden dining arm chairs in the main entrance showed significant wear and tear, including faded varnish, loose arms, and visible peeling and cracking of the upholstery on the seat, arms, and backrest. In the North dining room, five of five dining chairs had cracked or peeling vinyl upholstery, visible imprints or indentations on the seats, and worn varnish. The Administrator stated on 5/6/26 that the expectation was for furniture to be in good repair. The facility also failed to ensure a clean environment in Resident #43’s room. Resident #43 had diagnoses of COPD and diabetes, and the BIMS score was 15 out of 15, indicating intact cognition. During interview, the resident stated weekly housekeeping only involved sweeping and cleaning toilets, and that tables were not cleaned; the resident pointed to a table with multiple sticky rings. Maintenance staff, in the absence of the housekeeping supervisor, stated there was no current housekeeping manager and referenced budget cuts and staff changes. The Administrator later stated the facility was actively looking for a housekeeping manager to replace the one who left to improve housekeeping.
Failure to Complete QAA Activities
Penalty
Summary
The facility failed to carry out QAA activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impacted quality of care, quality of life, and resident safety. Based on review of QAPI meeting documentation, policy review, and staff interview, the facility had no documentation related to QA activities targeted at restorative services and staffing. The facility’s QAPI and QAA Plan, revised 1/2/25, stated that the facility would gather QAPI data from sources such as survey findings and carry out systematic action and analysis to achieve the desired outcome. The report also references prior CMS 2567 concerns for F584 and F688 and notes that the current survey, conducted 5/4/26 to 5/7/26, identified the same concerns.
Failure to Hold Required Quarterly QA Meetings
Penalty
Summary
The facility failed to carry out Quality Assessment Assurance (QAA) activities by not holding required quarterly QA meetings to identify issues with respect to QAA activities. Review of QAPI meeting attendance logs from the period of the last survey on 5/8/25 to the current survey on 5/4/26 showed no documentation of a QAPI meeting from 6/26/25 through 12/31/25. The facility QAPI and QAA Plan, revised 1/2/25, stated that the facility would establish Performance Improvement Plans (PIPs) and staff would review them no less often than quarterly. On 5/7/26 at 1:42 p.m., the Administrator stated the facility conducted QA monthly meetings, but it was clear that some months in the last year were missed.
Failure to Honor Resident Request for Staff Masking
Penalty
Summary
The facility failed to honor a resident’s request that staff wear a mask before entering the room. Resident #5 had diagnoses of COPD and respiratory failure, and the MDS documented intact cognition with a BIMS score of 15 out of 15. The care plan, revised on 3/18/26, identified a potential for infection related to a history of pneumonia and influenza and included an intervention that the resident prefers staff wear a mask and should be asked before entering the room. On 5/4/26, an RN was observed leaving the resident’s room without a mask and stated the signage on the door was only for strangers. Later that day, the resident stated staff had been asked to wear masks, had asked for masks to be brought to the room, and had requested a sign reading, “Please wear a mask.” On 5/5/26, an LPN was observed leaving the room wearing a mask and stated the resident wanted masks worn for her protection. On 5/7/26, the resident again stated a preference for masking before entry and reported that compliance varied despite the sign on the door. The Administrator stated the resident preference should be supported, was aware of the sign, had supplies of masks, and would expect staff to respect the resident choice.
Missing Pre-Hire Criminal Background Check
Penalty
Summary
The facility failed to conduct a criminal background check prior to hire for 1 of 2 newly hired employees. The undated New Hire List and Roster listed Staff J, a Certified Medication Aide, with a hire date of 8/14/25, but Staff J's personnel file did not contain documentation of a criminal background check completed upon hire. On 5/7/26 at 9:20 a.m., the Interim Administrator stated there was no other employee file documentation and that he was aware there were concerns with the files. On 5/7/26 at 11:36 a.m., the DON stated criminal background checks should be done before hire. The facility's Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated 3/18/26, stated the facility would carry out criminal record checks on all prospective employees.
Failure to Provide Bed Hold Information and Ombudsman Notification
Penalty
Summary
The facility failed to provide bed hold information for 2 of 2 residents who were admitted to the hospital, and failed to notify the ombudsman of hospitalizations for 1 of 2 residents. Resident #8 had diagnoses including end stage renal disease, blindness, and abnormalities of breathing, and the MDS dated 4/23/26 showed a BIMS score of 15 out of 15, indicating intact cognition. Progress notes documented transfers to the Emergency Room on 12/26/25 and 1/9/26, with returns to the facility on 1/6/26 and 1/13/26, but the record lacked documentation that bed hold information was provided for these hospitalizations and lacked documentation of ombudsman notification. Resident #49’s EHR showed an initial admission to the facility, then unpaid hospital leave beginning 1/27/26 with return on 2/3/26, unpaid hospital leave again beginning 2/8/26 with return on 2/19/26, and another transfer to the hospital on 3/8/26. Review of progress notes showed a bed hold form was sent only for the 2/8/26 hospitalization, and the EHR did not document whether bed hold was completed for the hospitalizations beginning 1/27/26 or 3/8/26. The facility’s policy stated residents would be notified of their rights regarding holding a bed when transferred to the hospital, and the DON stated staff should provide bed hold information when residents transfer to the hospital.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to complete and transmit a Comprehensive MDS assessment after a significant change in condition for one resident who enrolled in hospice care. The resident’s EHR Census Line documented hospice enrollment, and the MDS section showed a Significant Change MDS as in process with an ARD of 5/6/26, but the assessment had not been completed. On 5/6/26 at 2:26 pm, the MDS Coordinator stated she had not been informed that the resident had enrolled in hospice and therefore had not set up or completed a Significant Change assessment. She stated the facility needed better communication and that other staff were supposed to notify her, adding that she regularly checked the census line but could miss a change if she was not informed by other staff. The 2024 RAI Manual states that a Significant Change comprehensive assessment must have an ARD no later than the 14th calendar day after the determination that a significant change occurred, and that a Significant Change MDS is required when a terminally ill resident enrolls in hospice. The facility policy titled MDS 3.0 Completion also states that a Significant Change in Status Assessment is required within 14 days of identifying a qualifying status change, including when a resident enrolls in hospice, changes hospice providers while remaining in the facility, or revokes hospice care and remains in the facility.
Inadequate Assistance With Resident Bathing
Penalty
Summary
The facility failed to ensure adequate bathing assistance for 2 of 4 residents reviewed for activities of daily living, Resident #11 and Resident #27. Resident #11 had diagnoses including hemiplegia, stroke, and bipolar disorder, and her MDS dated 3/17/26 indicated she required substantial/maximal assistance with bathing and had a BIMS score of 14 out of 15. She told surveyors on 5/4/26 that staff did not assist her regularly with showers and that a week had elapsed between showers, making her feel dirty and stinkin'. Her care plan directed staff to assist with bathing and encourage bathing twice per week. Review of shower documentation for April 2026 showed baths on 4/3, 4/8, 4/11, 4/12, 4/13, and 4/29, with one declined shower on 4/7; the facility lacked documentation of additional baths and lacked documentation that staff re-approached her later after she declined. Resident #27 had diagnoses including heart failure, diabetes, and seizures, and her MDS dated 4/7/26 indicated she required partial to moderate assistance with bathing and had a BIMS score of 13 out of 15. She stated on 5/4/26 that two weeks elapsed between showers and that this was normal around here; she also reported being told she could not have a shower because there were only two aides, which made her feel dirty. Shower records for April 2026 showed baths on 4/3, 4/10, 4/11, 4/12, 4/13, 4/17, 4/24, and 4/28, with no documentation of additional baths or re-approaching the resident after a declined bath. Staff interviews stated showers were missed because of staffing issues, and the DON stated that if a resident missed baths, they received it on another day.
Failure to Provide Restorative Walking Program
Penalty
Summary
The facility failed to provide a restorative program to maintain mobility for one resident reviewed for restorative services. The resident had diagnoses including hemiplegia, stroke, and bipolar disorder, and had a BIMS score of 14 out of 15, indicating intact cognition. The resident stated she experienced a decline each time she finished therapy services, reported that she walked with PT but staff did not walk with her afterward, and could not recall when she last walked. Her care plan directed staff to assist with walking using an upright walker, AFO, and a strap for the left lower arm for up to 50 feet, and the PT discharge summary documented that she walked 75 feet with CGA at discharge on 3/13/26. The resident’s clinical record did not contain documentation that staff walked with her from the PT discharge date through the survey date. A PTA stated the therapists should have made restorative program recommendations, but they did not because the facility did not have staff to carry out a restorative program, and the facility had started a new restorative program only the week before the interview. A CNA stated the restorative program had started about 2 weeks earlier and that she did not walk with the resident or receive direction to do so. The DON stated the restorative program was new and she did not know why there had not been one before, but expected a restorative program to be in place at all times. The facility policy stated it would provide maintenance and restorative services designed to maintain or improve residents’ abilities to the highest practicable level.
Failure to Assess Dialysis Access Site on Non-Dialysis Days
Penalty
Summary
The facility failed to assess a dialysis access site on non-dialysis days for one resident who required dialysis services. Resident #8 had diagnoses that included end stage renal disease, blindness, and abnormalities of breathing, and the MDS dated 4/23/26 showed a BIMS score of 15 out of 15. The care plan entry dated 1/25/25 directed staff to complete a dialysis flow sheet daily to observe for access site complications. The April and May 2026 MARs directed staff to assess the resident's dialysis access site on Mondays, Wednesdays, and Fridays for signs and symptoms of infection or bleeding, and to remove the pressure dressing on Tuesdays, Thursdays, and Saturdays. However, from 4/1/26 through 5/4/26, the MAR lacked documentation of an arm assessment every Sunday, including 4/5/26, 4/12/26, 4/19/26, 4/26/26, and 5/3/26. The facility policy stated the nurse would check the dialysis access site every shift. The ADON, an RN, an LPN, and the DON stated staff checked the access site on dialysis days but did not complete assessments on non-dialysis days, and the ADON could not locate documentation of those assessments.
Failure to Verify CMA Certification Before Hire
Penalty
Summary
The facility failed to verify the validity of a Certified Medication Assistant (CMA) certification before hire for 1 of 1 newly hired CMAs. The undated New Hire List and Roster listed Staff J, CMA, with a hire date of 8/14/25, but the facility lacked documentation showing verification of Staff J's CMA certification. The facility policy titled License Verification, revised in 2025, stated that the facility would verify all personnel certifications. During interview on 5/7/26 at 11:36 a.m., the DON stated that CNA verification and criminal background checks should be completed before hire.
Stock Medications Not Available for Two Residents
Penalty
Summary
The facility failed to ensure prescribed stock medications were available for two residents reviewed for medication administration. Resident #6 had orders for MiraLax 17 grams by mouth each morning for constipation and Lidocaine 4% OTC patches to the lower back twice daily for pain, but the April 2026 MAR showed repeated codes of 11, indicating the medications were not available, for the scheduled MiraLax doses on 4/27/26 through 4/30/26 and for multiple Lidocaine patch administration times on 4/16/26 through 4/23/26 and again on 4/28/26 through 4/30/26. Resident #2 had an order for Lidocaine Pain Relief External Patch 4% to the left upper arm at bedtime with removal at 0759, but the April 2026 MAR showed repeated codes of 11 for both removal and application times on multiple days, and additional missed applications on 4/26/26 and 4/27/26. During interview, Resident #2 stated he had gone several days without lidocaine patches and said the facility ran out of medication frequently. Staff interviews confirmed the facility frequently ran out of stock medications such as lidocaine patches and that if the facility ran out over the weekend, replacement medication might not be obtained until the following Thursday unless someone went to Walmart to get some. The DON stated stock medication orders had been a problem and extra supplies were being ordered.
Call Lights Not Working or Out of Reach
Penalty
Summary
The facility failed to ensure call lights functioned or were within reach for 2 of 24 residents reviewed for call light accommodations. Resident #1 had diagnoses including heart failure, depression, and alcohol dependence, and his MDS showed a BIMS score of 15 out of 15. He stated his call light had stopped working about 3 weeks earlier. When an RN tested the call light, it did not turn on on the first and third attempts, and the Maintenance Director stated staff had not reported the problem before the day prior and that a new part was needed to fix it. Resident #1 later stated he had told a CNA about 3 weeks earlier that the call light did not work. Resident #11 had diagnoses including hemiplegia, stroke, and bipolar disorder, and her MDS showed a BIMS score of 14 out of 15. During observation, she was lying in bed with her call light on the floor out of reach, and the State Agency informed staff so they could provide it to her. The facility policy stated staff would ensure the call light was within resident reach and would report problems with the call system immediately. The DON stated that if a call light was not working, staff would provide a bell and enter a maintenance order, and that call lights should be in reach of the resident.
Missing Required Abuse Reporting Training
Penalty
Summary
The facility failed to ensure that 1 of 5 staff members reviewed for Dependent Adult Abuse (DAA) Mandatory Reporter's Training had current training. Personnel file review showed that Staff J, a Certified Medication Aide with a hire date listed as 8/14/25 on the undated New Hire List and Roster, did not have documentation of completing the required DAA Mandatory Reporter's Training within 6 months of hire. During interview on 5/7/26 at 9:20 a.m., the Interim Administrator stated he had no other employee file documentation and was aware there were concerns with the files. The facility policy titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting, dated 3/18/26, stated that within 6 months of hire each employee was required to complete 2-hour DAA training.
Failure to Maintain Head-of-Bed Elevation and Abdominal Binder During Continuous PEG Feeding
Penalty
Summary
The deficiency involves the facility’s failure to maintain appropriate positioning and use of an abdominal binder for a resident receiving continuous PEG tube feedings. The resident was cognitively impaired, diagnosed with paraplegia, non-Alzheimer’s dementia, and malnutrition, and was dependent on continuous gastric tube feedings to meet nutritional needs. Physician orders specified NPO status, continuous Glucerna 1.2 at 75 mL/hr via PEG tube, and an abdominal binder to be worn at all times, placed on backwards to prevent removal by the resident. On multiple observations, the resident was found in bed with the head of the bed flat while the feeding pump continued to run at 75 mL/hr, and without the ordered abdominal binder in place. The PEG tubing was also observed under tension when the resident self-transferred from wheelchair to bed while the feeding remained attached to a pole fixed to the wheelchair. Throughout the observation period, nursing staff, including an RN and a CNA, passed by or entered the resident’s room several times without elevating the head of the bed or ensuring the abdominal binder was applied, despite acknowledging in interviews that the head of the bed should be elevated at least 30–45 degrees during continuous tube feeding and that the binder was required to prevent the resident from pulling out the PEG tube. The facility’s policy on care and treatment of feeding tubes stated that feeding tubes would be used in accordance with current clinical standards of practice with interventions to prevent complications, but it did not provide specific direction on head-of-bed positioning while a feeding pump was running. These actions and omissions led to the identified deficiency in providing appropriate care for a resident with a feeding tube.
Failure to Renew Time-Limited Discharge Medications Resulting in Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident remained free from significant medication errors when routine medications were not reordered prior to the exhaustion of the supply, resulting in three full days without multiple prescribed medications. The resident had a moderate cognitive impairment with a BIMS score of 11/15 and diagnoses including Alzheimer’s disease, diabetes mellitus, thyroid disease, and atrial fibrillation. The resident had been admitted in early December with a series of hospital discharge medication orders written for 20 days. Review of the December Medication Administration Record (MAR) showed that numerous medications, including aspirin, atorvastatin, bupropion, vitamin D3, divalproex, donepezil, duloxetine, empagliflozin, levothyroxine, pantoprazole, polyethylene glycol, amiodarone, budesonide, Eliquis, formoterol, metoprolol, senna, and carbidopa-levodopa, were administered through December 28 but then had no further doses scheduled for December 29–31, as indicated by "x" marks for all scheduled times on those dates. Review of the January MAR revealed that many of these same medications were not scheduled at all, indicating that they had not been renewed after the initial 20‑day period. An ED note from early January documented that the resident’s daughter called EMS because the resident was missing appointments and medications had been stopped without explanation, and the daughter reported the resident appeared more confused and was not eating; the ED note further stated that, upon speaking with the pharmacy, it appeared the resident’s discharge medications from previous visits had not been renewed while she was going between rehab hospitals. Staff interviews confirmed that the medications were not administered on December 29, 30, and 31, and that there was no documentation that nurses had brought the 20‑day duration of the discharge medications to the provider’s attention. Nursing staff and leadership interviews revealed confusion and inconsistent understanding of responsibility for renewing time‑limited hospital discharge orders. One RN stated that when a resident has medications ordered for a certain time frame after admission, the nurse is responsible for notifying the physician to renew the orders, but also suggested that perhaps the pharmacy did not send the medications and reported believing it was the pharmacy’s responsibility to notify the doctor for renewal. Another RN verified that the resident’s medications were not administered for three days and described that an "X" on the MAR would indicate a scheduled medication, and that if a medication was not given there should be another code to indicate the reason; she also stated that if a medication was discontinued it would not appear on the MAR during pass and that the facility NP was responsible for reviewing medications after a hospital return. The NP could not recall the specific issue or explain why some medications had been discontinued. The DON stated she would have expected the nurse to question why medications were written to be discontinued after 20 days and to speak with the provider, and the ADON stated the nurse should always give discharge paperwork to the provider; the DON verified there was no documentation that nurses had alerted the provider about the 20‑day duration. Facility policies on Medication Reconciliation and Medication Reordering required systematic verification, transcription, ordering, and reordering of medications, including reordering when six or fewer doses remained, but these processes were not effectively carried out for this resident’s time‑limited discharge medications.
Failure to Maintain Safe and Clean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple environmental concerns observed during a survey. Staff interviews revealed that a hopper used for hygienic disposal of body waste had been out of order for an extended period, and the facility was in the process of obtaining bids for its repair. Additionally, staff acknowledged that the floors throughout the facility required cleaning and stripping. Direct observations identified several deficiencies in resident rooms, including moderate rust and missing paint on heating/air conditioning units, heavy buildup of dirt and dark substances on floors, and the presence of a moderate amount of black substance on baseboards. Multiple rooms were noted to have moderate to heavy buildup of dark-colored grime on the floors. Review of the facility's policy on routine cleaning and disinfection confirmed that these practices were not being consistently followed, as required to maintain a safe and sanitary environment.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to administer medications as prescribed by physicians for two residents. For one resident with chronic pain, COPD, and diabetes, there was a lapse in the administration of scheduled Hydromorphone for pain management. The resident reported not receiving the medication for approximately 20 hours, receiving only an alternative medication that was not effective. Documentation showed multiple missed doses, and staff interviews confirmed that the medication was not ordered in time, compounded by delayed delivery due to bad weather. The medication administration record indicated missed doses, and progress notes reflected that staff had to contact hospice for a new supply after the medication ran out. For another resident with asthma, COPD, and other chronic lung disease, a provider ordered new medications, including an antibiotic, corticosteroid, and inhaler, due to ongoing respiratory symptoms. However, these medications were not started over the weekend as ordered, and administration only began several days later. Staff interviews confirmed that the delay was due to a failure to order the medications in a timely manner. Facility policy requires medications to be administered safely, timely, and as prescribed, but this was not followed in these cases.
Failure to Provide Restorative Program for Residents at Risk of Physical Decline
Penalty
Summary
The facility failed to provide a restorative program for three residents who were at risk of physical decline due to their medical diagnoses and risk of falls. Clinical record reviews and care plans for these residents indicated the need for interventions such as encouraging exercise, providing opportunities for physical activity, and therapy evaluations. Despite these documented needs, observations and interviews revealed that none of the residents were participating in a restorative program, and their requests to use exercise equipment or participate in exercises were denied due to lack of staff or program availability. One resident with chronic obstructive pulmonary disease, pain, diabetes, and spinal stenosis expressed a desire to use the exercise bike to help with leg pain and mobility but was told he could not use it without staff supervision, which was unavailable. Another resident with cerebral palsy and mobility issues reported that he previously used the exercise bike but was no longer able to do so because the facility lacked staff to oversee the activity. He felt he was getting weaker as a result. A third resident with morbid obesity and respiratory failure also wanted to use the therapy room equipment but was similarly denied due to staffing shortages. Staff interviews confirmed that there was no restorative program in place at the facility, and the occupational therapist stated that although she had identified residents who would benefit from such a program, it had not been implemented. The facility's own policy required restorative nursing care to promote safety and independence, but this was not being followed. The administrator acknowledged the absence of a restorative program and indicated that other issues had taken priority.
Insufficient Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by prolonged call light response times and staff and resident reports of inadequate staffing. Observations showed that call lights in resident rooms remained unanswered for extended periods, such as one instance where a call light was activated at 10:40 AM and not answered until 10:58 AM, and another where a resident's call light was activated at 12:15 PM and not addressed until 12:38 PM. During these periods, residents were observed waiting for assistance, including one resident who was unable to begin eating lunch until staff responded to her call light and assisted her with positioning in bed. Interviews with staff and residents confirmed that staffing levels were insufficient, particularly on the East Hall, where only one aide was scheduled instead of the usual two. Residents reported that call lights often went unanswered for up to an hour on all shifts when staffing was low, and staff corroborated that they sometimes had to work late to complete resident care tasks such as baths. The facility's own policy requires timely response to call lights and holds all staff responsible for responding, but these procedures were not consistently followed due to inadequate staffing.
Failure to Follow Physician Orders and Inadequate Wound Care Documentation
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for two residents, resulting in multiple deficiencies. For one resident with complex medical conditions including peripheral vascular disease, renal failure, and recent abdominal surgery, staff did not implement or document physician-ordered treatments as prescribed. Orders for wound care, medication administration, and dietary management were not consistently followed. For example, wound dressings were not changed as frequently as ordered, and medications such as potassium chloride and ferrous sulfate were not administered according to the prescribed schedule. Additionally, significant weight loss was not communicated to the physician, and there was no documentation of the resident's refusal to participate in therapy or the absence of bowel movements. Wound assessments for the same resident were incomplete, lacking essential details such as wound measurements, tissue condition, drainage, and signs of infection. The clinical record did not contain accurate or sufficient documentation of wound status or physician notification regarding the resident's deteriorating condition. During a physician visit, it was noted that all dressings were dated several days prior and had not been changed as ordered, and the resident reported not having a bowel movement for several days. The resident was subsequently hospitalized for failure to thrive, poor wound healing, and weight loss. For another resident with a history of cancer and surgical wound infection, staff failed to follow wound care orders by not using the prescribed wound cleanser and documenting wound care as completed when it had not been performed. Observations revealed wound drainage on the resident's clothing and that wound care supplies were available but not used as ordered. Staff interviews confirmed that wound care was not always provided according to physician instructions, and documentation practices did not accurately reflect the care delivered.
Failure to Assess and Care Plan for Resident Self-Administration of Medication
Penalty
Summary
A deficiency occurred when the facility failed to assess and care plan for a resident to self-administer medications. The resident, who had diagnoses including heart failure, diabetes, and shortness of breath, was noted to have intact cognition with a BIMS score of 14 out of 15. The care plan addressed diuretic therapy for hypertension, and the medication administration record showed an order for bumetanide 1 mg twice daily. During observation, the resident was found with a pill in a medication cup at the bedside and stated it was a pill to make him urinate, indicating he had access to the medication before staff ensured it was taken. Staff interview confirmed that the LPN checked on the resident and verified the pill was taken after the fact. However, the clinical record did not contain documentation that the resident was assessed as safe to self-administer medications. Facility policy requires that residents may only self-administer medications if the attending physician and the interdisciplinary care planning team determine the resident has the decision-making capacity to do so safely. This process was not documented for the resident involved.
Failure to Provide Notice of Medicare Non-Coverage at Discharge
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to a resident who was discharged from skilled nursing services under Medicare Part A. Clinical record review showed that the resident had a planned discharge to home and was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident was capable of independently understanding written instructions. However, there was no documentation of the required NOMNC being given to the resident at the time of discharge. Interviews revealed that the responsibility for completing beneficiary notification forms, including the NOMNC, had recently shifted from the business office to the social worker. The social worker, who had started a few weeks prior, did not complete the NOMNC for the resident due to a lack of training. The administrator confirmed the absence of a facility policy addressing beneficiary notification of non-coverage and acknowledged that the resident did not receive information on appeal rights as a result.
Failure to Ensure Safe Positioning During Meals
Penalty
Summary
A deficiency was identified when a resident with a history of hemiplegia, cerebral infarction, and dysphagia was repeatedly observed eating meals while lying in bed with the head of the bed elevated less than 15 degrees. The resident's care plan noted risks related to altered nutritional status and swallowing difficulties. Despite this, multiple observations showed the resident eating in a reclined position, and the resident reported some difficulty eating in that position. Staff interviews revealed inconsistent practices, with some staff stating they positioned the resident upright for meals, while others acknowledged the resident sometimes refused to be repositioned. The Director of Nursing confirmed that residents should be upright during meals, but stated the resident was resistant to having the bed elevated. The facility did not have a policy on positioning residents while eating. The lack of consistent implementation of safe positioning practices and absence of a formal policy contributed to the failure to ensure the resident was positioned safely during meals, as required to prevent accidents such as choking.
Failure to Implement Bladder Training and Maintain Catheter Care Standards
Penalty
Summary
The facility failed to develop and implement interventions to attempt to restore or improve bladder function for a resident with urinary incontinence. The resident, who had diagnoses including heart failure and diabetes and was assessed as always incontinent of urine and frequently incontinent of bowel, was found to have intact cognition and the ability to communicate the urge to void. Despite an assessment indicating the incontinence was likely reversible and that the resident could participate in a toileting program, there was no evidence in the clinical record of a bladder training program or other interventions being carried out to address the incontinence. The resident also reported not recalling any bladder training or interventions to assist with regaining continence. Additionally, the facility failed to ensure proper catheter care for another resident with a suprapubic catheter. Observations showed that the resident's catheter tubing and drainage bag were repeatedly found resting on or dragging along the floor, both in the resident's room and in the hallway. Staff were observed rehanging the tubing and bag, but the issue persisted, with the tubing continuing to come into contact with the floor and being stepped on by the resident. Multiple staff members acknowledged having seen the tubing on the floor and identified concerns about cleanliness and the potential for the catheter to be pulled. Facility policy required that catheter tubing and drainage bags be kept off the floor and that appropriate services and treatment be provided to help restore or improve bladder function. Despite these policies, the facility did not implement a toileting plan or bladder training for the resident with incontinence, nor did it consistently ensure that catheter tubing and drainage bags were kept off the floor for the resident with a suprapubic catheter.
Failure to Prime Insulin Pen Prior to Administration
Penalty
Summary
A Licensed Practical Nurse (LPN) failed to prime an insulin pen prior to administering insulin to a resident diagnosed with diabetes, depression, and lack of coordination. The resident was observed receiving insulin injections daily, and during the observed medication administration, the LPN stated that priming was only necessary for the first use of the pen. The LPN proceeded to inject the resident with four units of insulin without priming the pen, contrary to the manufacturer's instructions, which require priming before each injection. Review of the resident's medication orders confirmed the use of a Humalog KwikPen with a sliding scale for insulin administration. The facility's policy on administering medications emphasized safe and timely administration as prescribed, but there was no specific policy regarding insulin pen use. The Director of Nursing confirmed that staff should prime insulin pens prior to each injection, and the manufacturer's instructions also directed priming before every use.
Staff Vaping in Common Areas Violates Resident Rights and Facility Policy
Penalty
Summary
Staff members were observed using nicotine vape pens in common areas of the facility, specifically in offices located off the dining room and during activities such as bingo, while residents were present. Multiple staff, including a CNA, CMA, and housekeeping, reported witnessing activities staff and office staff vaping inside their offices, with doors open and in close proximity to residents. These actions occurred despite the facility having a designated outdoor smoking area and a policy prohibiting the use of tobacco products, including vapes, in patient care areas and non-designated locations. The facility's Tobacco Policy, dated 9/21/23, clearly directed that employees are only permitted to use tobacco products in designated areas and are not allowed to carry such items in patient care areas. Despite this, staff interviews confirmed repeated violations of this policy, with vaping occurring in offices adjacent to resident common areas and during resident activities. The DON acknowledged observing this behavior and stated she directed the staff member to stop, while the Administrator claimed to be unaware of such incidents.
Failure to Assess and Notify Physician After Resident-Reported Seizure Activity
Penalty
Summary
The facility failed to assess a resident and notify the physician after the resident self-reported seizure activity. The resident, who had a documented history of seizure disorder, multiple sclerosis, cerebrovascular accident, schizophrenia, and depression, was cognitively intact and reported experiencing multiple seizures per day. The care plan included specific interventions for post-seizure treatment, documentation, and seizure precautions, and there was a physician order to notify neurology if an increase in seizures was noted. Despite these directives, clinical record review showed only one documented note of a self-reported seizure during the review period, with no further documentation of seizure activity. Multiple staff interviews revealed that the resident frequently reported seizures to staff, who would either check on her or report to the charge nurse. However, nursing staff, including an RN and LPN, admitted to not notifying the neurology provider regarding the resident's reported increase in seizures, as required by the physician's order and facility policy. The facility's policy required prompt notification of the physician for changes in a resident's condition, including specific instructions to notify for changes such as increased seizure activity. Staff interviews indicated a lack of consistent assessment and documentation of the resident's reported seizures, and the required notifications to the physician or neurology provider were not made, despite repeated self-reports by the resident.
Failure to Employ Infection Prevention Specialist
Penalty
Summary
The facility failed to employ an Infection Prevention Specialist, which is a requirement for maintaining an effective infection prevention and control program. During a review of the facility's staff list, it was observed that there was no designated Infection Prevention Specialist or Infection Control Nurse. The Administrator, identified as Staff F, reported that the facility had lost both the Director of Nurses and the Assistant Director of Nurses approximately one month prior. The Assistant Director of Nurses had been responsible for infection control, and since their departure, the facility had not been able to find a suitable replacement for this critical role until the day before the surveyor's interview.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to standard and transmission-based precautions, specifically Enhanced Barrier Precautions (EBP), for four residents, leading to a deficiency in infection prevention and control. Resident #2, who had a surgical wound and an indwelling Foley catheter, did not have appropriate signage or personal protective equipment (PPE) available outside their room. Staff members entered the room and provided care without donning gowns, contrary to the care plan directives. Resident #3, who had open areas on the coccyx and underneath the right breast, also lacked EBP signage and PPE in their room. Staff provided incontinence care and wound dressing changes without wearing gowns, despite the care plan indicating the need for EBP. Similarly, Resident #5, with a suprapubic catheter, had no EBP signage, and staff failed to wear gowns during high-contact activities, such as incontinence care and catheter maintenance. Resident #4, who had a suprapubic indwelling urinary catheter, also did not have EBP signage or PPE readily available. Staff entered the room and performed care activities without donning gowns, as required by the facility's policy. Interviews with staff revealed a lack of awareness and education regarding EBP, compounded by the recent loss of the Director of Nurses and Assistant Director of Nurses, who were responsible for infection control oversight.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the needs of residents, resulting in delayed response times to call lights. On the morning of January 13, 2025, four call lights were observed blinking in the East Hall, indicating that residents in rooms 31, 37, 38, and 45 were requesting assistance. At that time, only one LPN, Staff A, was present on the wing, as the scheduled aide had not yet arrived due to car troubles. This staffing shortage led to prolonged response times, with the longest being 39 minutes for one of the rooms. Interviews with residents and staff revealed that the issue of delayed call light responses was not isolated. Resident #6 mentioned that call lights are sometimes not answered promptly when there is insufficient staff to assist with her transfers, which require two staff members. The Director of Nursing, Staff C, admitted to not regularly conducting call light audits unless a problem is reported, and no recent complaints had been noted. However, a call light audit conducted on January 14, 2025, confirmed the delays, and the Activities Director, Staff D, reported that residents had previously voiced complaints about call light response times during a resident council meeting in October 2024.
Failure to Ensure Proper Personal Hygiene in Kitchen
Penalty
Summary
The facility failed to ensure proper personal hygiene practices in the kitchen area, leading to a deficiency in food safety standards. During an observation, two male dietary employees were seen working in the kitchen with hair nets but without beard guards, despite having facial hair. This was contrary to the facility's policy, which mandates that all male employees with facial hair must wear beard guards. The Dietary Manager acknowledged the expectation for facial hair to be covered and admitted he had not noticed the staff's non-compliance at the time of the observation.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for two residents with moderate cognitive impairment. Resident #31, diagnosed with cerebral infarction, cognitive communication deficit, and dysphagia, was observed with a medication cup containing two white tablets on the bedside table. The resident indicated the medication was Tylenol and intended to take it later, despite the medication administration record showing the dose was signed as given by a Licensed Practical Nurse. There was no physician order for self-medication administration for this resident. Similarly, Resident #32, with diagnoses including obstructive hypertrophic cardiomyopathy, psychoactive substance dependence, and other conditions, was found with a medication cup containing several pills, including Gabapentin, unattended on the bedside table. The Certified Medication Aide could not identify the other medications and reported the medications were discarded. The facility's policy required medication staff to remain with residents until all medications were taken, which was not followed in these instances.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to protect a resident from environmental hazards, resulting in a resident acquiring first-degree burns from spilled coffee. Resident #4, who has severe cognitive impairment and physical behavioral symptoms, was not provided with adequate supervision or appropriate assistive devices, such as a lidded mug, to prevent the incident. Despite the resident's known morning tremors and jerky movements, staff did not implement necessary precautions, leading to the resident spilling hot coffee on herself. The care plan and dietary slip lacked updates or interventions to address the risk of hot liquid spills. Additionally, the facility did not ensure that another resident, Resident #28, was properly assessed for independent smoking. Despite having impaired decision-making and a history of smoking in undesignated areas, the resident was allowed to smoke independently without proper supervision. The resident frequently smoked outside the designated area, discarded cigarette butts improperly, and did not adhere to the facility's smoking policy. Staff inconsistently enforced the smoking policy, and the resident's care plan did not adequately address the risks associated with his smoking behavior. The facility's failure to identify and mitigate risks associated with hot liquids and smoking behaviors resulted in unsafe conditions for the residents. The lack of timely interventions and adherence to policies contributed to the incidents involving Resident #4 and Resident #28, highlighting deficiencies in the facility's supervision and environmental safety measures.
Inadequate Catheter Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate catheter care to prevent potential cross-contamination that could lead to urinary tract infections (UTIs) for two residents. Resident #17, who has severe cognitive impairment and a neurogenic bladder, was observed multiple times with the urinary drainage bag and tubing in direct contact with the floor. The care plan and Kardex for Resident #17 directed staff to wear protective gear during high-contact care and to position the catheter bag below the bladder level, but they lacked specific instructions to keep the bag and tubing off the floor. Observations revealed that the urinary drainage bag was often on the floor, and a family representative expressed concerns that this had contributed to past UTIs and hospitalizations. Resident #41, who has intact cognition and requires total staff assistance, was also observed with the catheter bag lying on the floor. The care plan for Resident #41 included goals to prevent catheter-related trauma and complications, but the observation indicated a failure to maintain proper catheter care. Interviews with staff, including a CNA and RN, confirmed that the expectation was to keep the urinary drainage bags off the floor by securing them to the bed frame. However, the facility lacked a specific policy for handling urinary drainage bags, relying only on a general infection control policy. The facility's infection control policy, last reviewed in 2020, aimed to prevent the transmission of infections and manage nosocomial infections. Despite this, the lack of specific guidelines for urinary drainage bag handling contributed to the observed deficiencies. The Administrator acknowledged the absence of a policy for urinary drainage bags and suggested using a wash basin to keep them off the floor, indicating a gap in the facility's infection prevention and control program.
Violation of Resident Dignity Due to Unauthorized Phone Use
Penalty
Summary
The facility failed to uphold the resident's rights and dignity for a resident on hospice care. The resident, who had severe cognitive loss and required substantial assistance for eating, was observed being assisted by a CNA who was using her personal cell phone during the meal. This action was against the facility's policy, which allows personal phone use only during breaks. The CNA attempted to conceal her phone when noticed by the surveyor and claimed it was due to a family emergency, although she did not show any emotional distress. The resident's care plan indicated a need for specific communication techniques and a homelike environment to maintain comfort, which were not adhered to during this incident. The facility's policies, including the Resident Rights and Responsibilities Policy and the Wireless Mobile Device Policy, emphasize the importance of maintaining a dignified existence for residents and restricting personal phone use to non-working times. Despite these policies, the CNA's actions during the meal compromised the resident's dignity and the facility's standards.
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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.
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Nursing homes near Iowa City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarwood Healthcare Center | 3.5 mi | ★★★★★ | 1 | 0 |
| Oaknoll Retirement Residence | 4 mi | ★★★★★ | 5 | 0 |
| Lantern Park Specialty Care | 6.3 mi | ★★★★★ | 0 | 0 |
| Crestview Specialty Care | 6.8 mi | ★★★★★ | 15 | 1 |
| Windmill Manor | 7.5 mi | ★★★★★ | 12 | 0 |
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