Oakland Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Oakland, Iowa.
- Location
- 737 North Highway St., Oakland, Iowa 51560
- CMS Provider Number
- 165230
- Inspections on file
- 33
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 43
Citation history
Health deficiencies cited at Oakland Manor during CMS and state inspections, most recent first.
A resident with paraplegia, neurogenic bowel and bladder, and a history of a recurrent stage 4 pressure wound was care planned for impaired skin integrity, but weekly skin and non‑pressure wound assessments failed to identify and document an open wound to the gluteal fold that was later described in a progress note as a granulating wound with drainage. The RN responsible for the weekly wound assessment acknowledged performing the assessment on a different day than recorded and focusing only on known areas of concern rather than completing a full head‑to‑toe skin assessment as required by facility policy. In addition, during an observed neurogenic bowel treatment and dressing change to a gluteal wound, two RNs repeatedly changed gloves without performing hand hygiene between glove changes, despite contact with stool and the wound area, contrary to the facility’s hand hygiene policy and the DON’s expectations for hand hygiene during wound care.
Surveyors found that call lights were not answered in a timely manner, with observations of a call light remaining unanswered for over 15 minutes and reports from cognitively intact residents that they frequently waited longer than 15 minutes for assistance. One resident with incontinence reported repeated delays on both shifts, while another resident with renal insufficiency, neurogenic bladder, and paraplegia reported waiting about 20 minutes to be helped to lie down. During a resident council meeting, several residents stated that call lights often took longer than 15 minutes to be answered, especially around shift changes. The DON’s stated expectation and facility policy required timely response and that all staff respond to activated call lights, but these were not consistently followed.
Two residents experienced failures in dignity and respectful treatment during care. One cognitively intact resident with quadriplegia and generalized muscle weakness was left in bed wearing only a brief, without sheets or clothing, while staff left the room to attend to other tasks; the resident reported feeling uncomfortable and that his dignity was not respected until staff later returned to cover him. Another resident with moderate cognitive impairment, hemiplegia, diabetes, and depression, who was totally dependent for personal care, reported that a CNA yelled at her, put her feet back in bed when she was attempting to get out, and tapped or slapped her upper leg, leading the resident to tell the CNA to leave the room; the CNA later denied striking the resident but acknowledged intervening to return her to bed.
Staff failed to promptly separate two residents during a physical and verbal altercation involving a cognitively impaired resident and another resident with behavioral health diagnoses. The incident occurred in the dining area over a dispute about silverware, resulting in one resident being struck in the chest. Staff interviews revealed that immediate separation did not occur, despite facility policy and care plans directing such action to prevent resident-to-resident abuse.
The facility did not complete a thorough investigation after two separate altercations involving a resident with severe cognitive impairment and two other residents. In both incidents, staff intervened and no injuries were reported, but the facility's investigative files lacked staff and resident interviews or statements. The administrator acknowledged that only charge nurse statements were obtained and admitted this was a failure in the investigative process.
A resident with severe cognitive impairment and a history of delusions was placed on one-to-one supervision after an altercation with another resident. Despite this intervention, staff failed to maintain the required supervision, resulting in a second altercation in the dining room. Staff interviews revealed confusion about supervision responsibilities and a lack of clear documentation or protocols for one-to-one supervision.
Two residents with cognitive and psychiatric diagnoses were involved in a physical altercation, resulting in one striking the other. Although staff intervened and attempted to notify management promptly, the incident was not reported to the State Agency within the required timeframe due to communication failures and the absence of the DON, leading to a delay in reporting the abuse allegation.
Two residents with mild cognitive impairment and complex medical histories were involved in a physical altercation, but their care plans were not updated to reflect the incident or to include new interventions, despite facility policy requiring timely care plan revisions by the interdisciplinary team.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
Feeding tubes were utilized for a resident without documented medical necessity or resident agreement, and appropriate care for a resident with a feeding tube was not provided.
The facility experienced repeated deficiencies in areas such as infection control, quality of care, notification of changes, and care plan management due to the failure to implement an effective QAPI program. Despite having a QAPI plan and procedures, the facility did not prevent recurring issues, as evidenced by multiple citations over several surveys.
Surveyors found that several residents with cognitive deficits were moved between rooms multiple times without documentation of notification or explanation to their representatives, despite facility policy requiring such communication. Interviews and record reviews confirmed that families were not informed, and staff were unaware of the notification policy.
The facility did not consistently notify physicians and resident representatives of significant changes in condition or treatment, including feeding refusals, weight loss, medication changes, high blood sugar, positive Covid-19 tests, and falls with injury. In several cases, families and physicians were not informed in a timely manner, and required documentation of notifications was missing.
The facility did not complete the required additional research for a CNA whose background check was flagged, and the necessary DHS documentation was missing from the employee file, contrary to facility policy.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not properly review and revise care plans for two residents. One resident's care plan did not reflect current feeding tube use and oral intake status, while another resident's care plan lacked goals and interventions related to an ongoing sexual relationship. Staff and policy reviews confirmed that care plans were not updated to match residents' current needs and conditions.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
A resident with paraplegia and total dependence on staff for ADLs did not receive showers as preferred, receiving only bed baths due to staff unfamiliarity with appropriate equipment and inconsistent documentation. The resident expressed a desire for regular showers, but was not consistently offered them, and staff only began using a shower bed after a prolonged period.
A resident with severe cognitive impairment and multiple medical conditions fell while attempting to transfer to the commode after being left alone, despite care plan interventions to prevent such incidents. Following the fall, staff did not complete or document several required neurological assessments at the specified intervals, as confirmed by the DON and clinical record review.
Staff were found to have not fully adhered to facility policies designed to protect a resident from abuse, including the inappropriate use of photographs or recordings. Despite clear policies and signed acknowledgments regarding resident rights and the prohibition of demeaning or unauthorized media use, there was a deficiency in ensuring these protections were consistently upheld.
A resident with a suprapubic catheter and multiple health conditions did not have urine output consistently monitored or documented as ordered by a physician. Despite staff being directed to record catheter output each shift and monitor for infection, records showed multiple days with missing documentation. Staff interviews revealed inconsistent practices regarding catheter output monitoring, resulting in a failure to follow care protocols for a resident at risk for urinary tract infection.
A resident did not receive sufficient food and fluids to maintain their health, as required. The facility failed to ensure the necessary provision of nutrition and hydration.
Surveyors observed that staff failed to follow infection control protocols, including proper hand hygiene, glove changes, and use of gowns during high-contact care for three residents with indwelling devices and wounds. Catheter bags were improperly placed, and Enhanced Barrier Precautions were not consistently implemented as required by facility policy and posted signage. Facility leadership confirmed these practices did not meet established infection prevention standards.
During a COVID-19 outbreak, the facility failed to enforce proper infection control measures. Staff and residents were observed not wearing masks, despite signs indicating mask requirements. PPE was available for COVID-19 positive rooms, but adherence to mask-wearing was inconsistent. Staff interviews revealed a shortage of N95 masks and a lack of signage indicating outbreak status. The outbreak involved 22 residents and 9 staff, traced back to a staff member, with one hospitalization reported.
The facility inaccurately submitted staffing reports for the CMS PBJ Staffing Data Report, showing excessively low weekend staffing and resulting in a one-star rating. The facility maintained equal staffing levels during the week and weekends, contrary to the reported data. The Administrator acknowledged the inaccuracy and stated that staffing followed the per patient day (PPD) formula.
The facility failed to implement proper infection control practices during resident care, medication administration, and laundry delivery. A resident with multiple medical conditions did not have appropriate signage for enhanced barrier precautions, and staff did not consistently perform hand hygiene during wound care. Additionally, staff mishandled medications without proper hand hygiene, and laundry was transported uncovered, contrary to facility policies.
The facility failed to provide residents with access to their personal funds, as residents could only obtain money during limited business office hours. Interviews with residents and staff revealed that funds were inaccessible at night or when specific staff were not present. Grievances were filed due to this issue, and the facility's current practice did not align with its policy, which stated that residents should have access to their funds at any time.
The facility did not maintain a sanitary and comfortable environment, as evidenced by unrepaired floor tiles in the north hall. The Maintenance Director, responsible for minor repairs, could not explain the delay in addressing the issue, despite monthly maintenance rounds and a system for logging repairs. The Corporate Director of Operations noted the lack of a specific policy for maintenance repairs.
The facility did not maintain food at a safe temperature during meal service. A cook recorded the breakfast sausage gravy at 180°F initially, but it dropped to 130°F an hour later. The Dietary Manager stated that staff should check temperatures throughout meal service, but the Corporate Director of Operations admitted there was no specific policy for holding temperatures.
The facility failed to properly label stored food, maintain sanitary practices, and ensure effective sanitizer concentration. An RN used a hand hygiene sink for resident water, and several food items were found unlabeled. The sanitizer solution was below the recommended concentration, violating facility policies.
The facility inaccurately assessed and documented the medical status of three residents in their MDS. One resident was incorrectly documented as using anticoagulant therapy instead of anti-platelet medication, another was wrongly recorded as receiving insulin therapy instead of Trulicity, and a third resident's catheter type was misrepresented. The errors were acknowledged by the ADON and DON.
The facility failed to provide comprehensive care plans for two residents, one on anti-platelet therapy and another with multiple diagnoses requiring enhanced barrier precautions (EBP). The care plans lacked necessary focus, goals, and interventions, as acknowledged by the DON.
Two residents were observed being pushed in wheelchairs without foot pedals, contrary to facility expectations and care plans. One resident, with normal cognitive function, required substantial assistance and was pushed by a CNA who had not received training on wheelchair use. Another resident, with severe cognitive impairment, was pushed by an LPN and observed self-propelling without foot pedals. The facility lacked a specific policy on foot pedal use, relying on Standards of Practice.
The facility failed to provide accurate and timely assessments and interventions for several residents. One resident was discharged with medications, including narcotics, without proper authorization. Another resident experienced a fall without receiving a complete assessment. Additionally, two residents had high and low blood glucose levels without proper physician notification.
The facility failed to ensure adequate discharge planning for four residents, leading to delays in receiving medications, lack of home health services, and emergency medical interventions. The residents were discharged without proper coordination of medications, follow-up appointments, or home health services, causing significant issues for the residents and their families.
The facility failed to follow standard infection control practices during incontinence care for a resident. Two CNAs did not change their gloves or perform hand hygiene after cleaning the resident's legs and buttocks, continuing to use the same gloves while putting on a clean brief and handling a mechanical lift. The resident required substantial assistance and had multiple diagnoses, including anemia and coronary artery disease.
The facility failed to notify resident representatives after falls for two residents. One resident with moderate cognitive deficits fell while pushing another resident in a wheelchair, and the family was not informed. Another resident with intact cognitive ability reported a fall after getting dizzy, but the emergency contact was not notified. The facility's policy required notifying the physician and resident representative of any change in condition, including accidents or incidents.
Failure to Accurately Document Skin Assessments and Perform Hand Hygiene During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to accurately assess and document a resident’s skin condition and to perform proper hand hygiene during pressure ulcer care. A cognitively intact resident with paraplegia, neurogenic bowel and bladder, renal failure, chronic pain, and a history of a recurrent stage 4 pressure wound to the left gluteal crease was care planned as being at risk for pressure ulcers and requiring regular skin monitoring and treatments. The quarterly MDS documented that the resident did not have a pressure ulcer, and a weekly nursing skin assessment recorded no alterations in skin integrity, despite a note that a small blister had been charted the previous day. A weekly non‑pressure wound assessment completed by the former ADON/wound nurse documented only a ruptured blister on the inner upper right hip and did not list any additional wounds. Progress notes later documented that, during a neurogenic bowel treatment, nursing staff observed an open skin impairment to the right gluteal fold with granulation tissue, defined borders, peeling/excoriated periwound skin, and serosanguineous drainage with purulent drainage, measuring 4.5 cm x 5.0 cm x 0.2 cm. The nurse cleansed and dressed this wound, indicating that a significant wound was present but had not been captured on the weekly skin or wound assessments. Staff interviews revealed that the nurse who completed the weekly non‑pressure wound assessment had actually performed the assessment on a different day than documented, focused only on known areas of concern, and did not perform a full head‑to‑toe assessment, contrary to facility policy requiring a full body skin assessment and documentation of all wounds and their characteristics. The facility also failed to ensure proper hand hygiene during a pressure ulcer treatment to the resident’s left gluteal fold. During observation of a neurogenic bowel treatment and dressing change, two RNs initially washed their hands, but one RN then touched her hair, picked up wipes from the floor, and moved a trash can before proceeding with care. Throughout the procedure, both RNs repeatedly doffed and donned gloves between steps such as removing the old dressing, cleansing the wound, and applying the new dressing, without performing hand hygiene between glove changes, despite handling stool and the wound area. The facility’s hand hygiene policy required staff to perform hand hygiene using proper technique consistent with accepted standards of practice, and the DON stated that hand hygiene should be performed between glove changes during wound treatments, but this was not followed during the observed care.
Delayed Call Light Response and Inadequate Nursing Staff Responsiveness
Penalty
Summary
Surveyors identified a deficiency related to inadequate nursing staff response to resident call lights, resulting in delays beyond the facility’s own expectation of a 15-minute response time. One resident with a BIMS score of 15 and documented as always incontinent of urine and bowels reported that it frequently took longer than 15 minutes for staff to answer call lights, occurring on both shifts. Continuous observation by surveyors showed a call light in the East hallway remained unanswered for 16 minutes. Another resident, also cognitively intact with a BIMS score of 15 and diagnoses including renal insufficiency, neurogenic bladder, and paraplegia, reported having his call light on while waiting to lie down and stated he had been waiting about 20 minutes, noting that such delays occurred from time to time. During a resident council meeting with multiple residents, participants reported that call lights could take longer than 15 minutes to be answered, particularly at most shift changes. The DON stated her expectation was that call lights be answered within 15 minutes or less. Review of the facility’s policy on call lights indicated that all staff members who see or hear an activated call light are responsible for responding. Despite this policy and stated expectations, surveyor observations, resident interviews, and documentation review showed that call lights were not consistently answered in a timely manner, contributing to the identified deficiency in providing adequate nursing staff response to meet residents’ needs.
Failure to Maintain Resident Dignity and Respect During Care Interactions
Penalty
Summary
Surveyors identified a failure to maintain resident dignity for a cognitively intact resident with quadriplegia and generalized muscle weakness who required assistance with personal care. The resident’s MDS documented a BIMS score of 15, indicating no cognitive impairment. On the observed date and time, a CNA (Staff C) left this resident in bed wearing only a brief, with no sheets or clothing. Staff C left the room and went down the hall to another room, then continued other tasks. During this period, the Activities Director entered the room to deliver mail while the resident remained uncovered. The resident subsequently activated the call light, reporting that staff had left to get linen and that he felt uncomfortable and that his dignity was not respected while lying in bed without a sheet. Staff did not return to cover him until several minutes later, at which time the resident was observed with a blanket on. The resident stated that it usually did not take that long for staff to return to cover him, which was why he used the call light. In a later interview, Staff C acknowledged working that morning, giving showers, and forgetting to put sheets on the resident’s bed. She stated she believed she was not supposed to have a bottom sheet on the air mattress and reported that when she returned to answer the call light, the resident asked to have the blanket put over him. Staff C stated she apologized to the resident and said she had gotten sidetracked. The facility’s dignity policy in effect at the time stated that it was the practice of the facility to protect and promote resident rights, treat each resident with respect and dignity, and maintain or enhance quality of life by recognizing individuality and maintaining privacy. Surveyors also identified a dignity-related concern involving another resident with moderate cognitive impairment (BIMS score of 08) and diagnoses including hemiplegia, diabetes, and depression, who was totally dependent on staff for personal hygiene and dressing. This resident reported that a CNA (Staff P) recently slapped her upper leg while putting her feet back up in bed after noticing her attempting to get out of bed. The resident stated that the CNA was very mean verbally, yelled at her, lifted her feet, put them back in bed, tapped her upper leg, and that she then told the CNA to get out of her room. In a subsequent interview, Staff P stated she assisted the resident back into bed when she saw her trying to get out, was focused on safety because the resident could not walk on her own, and denied touching the resident’s upper leg in the manner described. The facility’s Abuse Prevention policy defined mistreatment as inappropriate treatment or exploitation of a resident and stated that the facility is committed to protecting residents from abuse by anyone.
Failure to Separate Residents During Altercation
Penalty
Summary
The facility failed to separate two residents during a resident-to-resident altercation, resulting in one resident physically striking another. One of the residents involved had severe cognitive impairment, as indicated by a BIMS score of 3, and a history of delusions and impaired short-term memory. The care plan for this resident directed staff to reorient and redirect her as needed. The other resident had no cognitive impairment but had a history of anxiety, depression, and behavioral symptoms. Both residents had documented behavioral care plans that included redirection and education as interventions. On the day of the incident, dietary staff observed the cognitively impaired resident becoming verbally aggressive toward another resident over silverware. The resident then struck the other resident in the chest. Staff interviews revealed that the dietary manager did not immediately separate the residents, citing concerns about holding a coffee pot and the potential for aggression. The nurse was called to the scene, and only then were the residents separated. The resident who was struck denied injury and reported this was the first such incident. Further interviews with staff indicated that the standard response to such altercations would be to redirect and separate the residents, but this was not done promptly in this case. The facility's abuse prevention policy, provided during the investigation, commits to protecting residents from abuse, including from other residents. However, the failure to immediately separate the residents during the altercation constituted a lapse in following this policy and the residents' care plans.
Failure to Conduct Thorough Investigation After Resident Altercations
Penalty
Summary
The facility failed to conduct a thorough investigation following two separate resident-to-resident altercations involving a resident with severe cognitive impairment and two other residents with no cognitive impairment. The first incident occurred when a resident with a BIMS score of 3, indicating severe cognitive impairment, grabbed another resident's wheelchair and began pushing it, then slapped the resident several times on the shoulder after he attempted to remove her hand. The second incident involved the same cognitively impaired resident, who was reported to have hit another resident in the chest during a dispute over silverware. In both cases, staff intervened promptly to separate the residents, and no injuries were reported by the residents involved. Upon review, the facility's investigative files for both incidents were found to be incomplete. The documentation provided included summaries of the investigations, face sheets, care plans, medication changes, and progress notes, but lacked staff interviews or statements and resident interviews or statements. The administrator acknowledged that only statements from the charge nurses on duty were obtained and that no additional interviews with other staff or residents were conducted. The administrator also stated that the resident with severe cognitive impairment was not interviewed due to her condition, and that she did not perceive the resident as violent or capable of causing bodily injury. The deficiency was identified based on the facility's failure to follow a comprehensive investigative process after the altercations. The lack of thorough documentation, including the absence of interviews with all involved parties, contributed to the finding that the facility did not respond appropriately to the alleged violations. The administrator admitted this was a failure in the investigative process, as the standard procedure would typically involve gathering information from all relevant staff and residents.
Failure to Provide Required One-to-One Supervision for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide proper supervision for a resident with severe cognitive impairment, resulting in two separate altercations with other residents. The resident in question had a BIMS score of 3, indicating severe cognitive impairment, and diagnoses including hypertensive heart disease, anemia, renal failure, psychotic disorder, mild cognitive impairment, insomnia, and metabolic encephalopathy. The care plan for this resident included interventions for delusions and impaired short-term memory, with specific instructions for staff to reorient and redirect the resident as needed. Following an initial altercation with another resident, the care plan was updated to require one-to-one supervision while the resident was awake due to increased delusions. Despite the updated care plan, staff failed to maintain the required one-to-one supervision. On the day following the first incident, the resident was involved in a second altercation, this time with a different resident in the dining room. Staff interviews and documentation revealed that, although the resident was supposed to be under constant supervision, there was confusion among staff regarding who was responsible for the supervision at the time of the second incident. Staff members were occupied with other duties, such as assisting another resident who had fallen, and were not physically present with the resident as required by the care plan. The lack of clear assignment and documentation for one-to-one supervision contributed to the failure to prevent the second altercation. Further review of facility practices showed that there was no accessible documentation or clear protocol available to staff regarding the implementation of one-to-one supervision. The MDS Coordinator was unable to provide documentation for the supervision during the relevant period, and staff interviews indicated uncertainty about the expectations and procedures for one-to-one supervision. The administrator confirmed that staff were not within the required proximity to the resident during the incident, and there was no indication that alternative supervision measures, such as 15-minute checks, were implemented when one-to-one supervision could not be maintained.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving two residents. One resident, who had a history of dementia, schizophrenia, neurogenic bladder, and PTSD, and was assessed as having mild cognitive impairment, became agitated and physically struck another resident in the face after a verbal altercation. The incident occurred in a common area and was witnessed by nursing staff, who intervened to separate the residents. The facility's policy requires that allegations of abuse be reported immediately, but not later than two hours after the event if it involves abuse or results in serious bodily injury. Despite the policy, the incident was not reported to the State Agency until nearly two days later. The delay occurred because the charge nurse attempted to notify the Administrator shortly after the incident, but the Administrator did not respond until several hours later, citing personal errands. Additionally, the Interim DON had quit via text message on the day of the incident, contributing to the communication breakdown. The Administrator acknowledged that the late reporting was her responsibility and that the charge nurse had attempted to follow proper procedures.
Failure to Update Care Plans After Resident Altercation
Penalty
Summary
The facility failed to update the care plans for two residents following a resident-to-resident altercation. One resident, with a history of dementia, neurogenic bladder, schizophrenia, and PTSD, became agitated and physically aggressive, ultimately striking another resident in the face. The altercation was documented in progress notes, and both residents were separated by staff before further escalation. Despite this incident, a review of the care plans revealed that neither resident's care plan was updated to reflect the altercation or to include interventions to address the event. Interviews with staff indicated that responsibility for updating care plans lies with the nurse in charge or the individual completing the incident report, but the care plans remained unchanged after the incident. The facility's policy requires a person-centered care plan to be developed and revised by an interdisciplinary team to address residents' needs and incidents, but this was not followed in the case of these two residents. Both residents had mild cognitive impairment and relevant medical conditions at the time of the deficiency.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Ensure Medically Necessary Use and Proper Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the intervention. Additionally, appropriate care and services for a resident with a feeding tube were not provided as required. The report identifies a failure to ensure that feeding tubes are only used when medically necessary and with resident consent, as well as a lack of proper care for residents with feeding tubes.
Repeat Deficiencies Due to Ineffective QAPI Implementation
Penalty
Summary
The facility failed to ensure the implementation of a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies identified during multiple annual, revisit, and complaint surveys over a three-year period. Deficiencies cited included issues with notification of changes, quality of care, tube feeding management, infection control, development and implementation of abuse/neglect policies, accidents and hazards, nutrition/hydration status maintenance, care plan timing and revision, and services provided meeting professional standards. These deficiencies were documented through reviews of the Department of Inspections, Appeals, and Licensing website, which showed repeated citations for the same or similar issues across several surveys. Despite having a QAPI plan and procedures in place, the facility's actions did not prevent the recurrence of these deficiencies. The QAPI documentation described a structured, data-driven approach involving interdisciplinary teams and input from residents and staff, with processes for identifying and addressing quality care and process improvement opportunities. However, the repeated nature of the cited deficiencies indicates that the QAPI program was not effectively implemented or sustained, resulting in ongoing noncompliance with regulatory requirements related to quality assurance and performance improvement.
Failure to Notify Residents or Representatives of Room Changes
Penalty
Summary
The facility failed to notify residents or their representatives of room changes or provide explanations for these changes for four residents with varying degrees of cognitive impairment. Observations, interviews, and record reviews revealed that residents with severe to moderate cognitive deficits were moved between rooms multiple times without documentation of family notification or explanation for the moves. In several cases, residents exhibited behaviors such as wandering, confusion, and verbal altercations, yet there was no evidence that families were informed or involved in care conferences regarding these changes. For example, one resident with a history of wandering and elopement risk was moved four times, and her family reported not being notified or invited to care conferences. Another resident, also with severe cognitive impairment and anxiety, was moved twice in a short period, with nursing notes indicating increased confusion and distress, but no documentation of family notification or rationale for the moves. Additionally, two other residents with moderate cognitive deficits and complex medical histories were moved between rooms without documented explanations or notifications to their families. The facility's policy required social services to complete a room change form and notify residents or their representatives, but staff interviews indicated a lack of awareness of this policy. The administrator acknowledged that the social worker was not aware of the notification policy and stated that she would expect staff to communicate with residents and their representatives prior to room changes. However, the records reviewed did not show that these procedures were followed.
Failure to Notify Physicians and Representatives of Changes in Condition
Penalty
Summary
The facility failed to notify physicians and resident representatives of significant changes in condition or treatment for four residents. For one resident with a history of cancer, dysphagia, and a feeding tube, there were multiple refusals of enteral and oral feedings, as well as a documented weight loss of 5 pounds in one week and a total loss of over 25 pounds since the previous year. Despite care plan interventions requiring physician notification for significant weight loss and feeding refusals, there was no evidence that the physician was informed of these changes. Staff interviews confirmed that such notifications should have occurred, and the physician stated she was only recently made aware of the resident's weight loss and refusals. Another resident with diabetes and psychiatric diagnoses experienced a change in psychotropic medication and a critically high blood sugar reading. The resident's Power of Attorney (POA) was not notified of the medication change until behavioral symptoms emerged, and there was a delay in notifying both the POA and physician about the high blood sugar. Documentation of physician notification and orders for insulin was lacking in the medical record, and staff confirmed that notification should have been made for such changes in condition. Additional deficiencies included failure to notify a resident's family of a positive Covid-19 test result and failure to inform a family member of a fall resulting in injury, despite care plan interventions and facility policy requiring such notifications. In one case, the family only learned of a positive Covid-19 result after calling the facility following an automated message, and in another, the family was not informed of a fall with injury until contacted by hospice. The facility's policy required timely notification of changes in condition, but documentation and interviews revealed that these notifications were not consistently made.
Failure to Complete Required Background Check Research for CNA
Penalty
Summary
The facility failed to complete the required additional research for a Certified Nursing Assistant (CNA) whose background check indicated further investigation was necessary. The CNA was hired and had a background check completed, which documented that additional research was required. However, the employee file did not contain the Department of Human Services (DHS) release indicating whether the CNA was eligible to work in the facility following the additional criminal history research. Interviews with facility staff revealed that the process for handling flagged background checks involved notifying the employee, collecting additional paperwork, and waiting for DHS results before allowing the individual to work. Despite this, the necessary documentation was missing from the CNA's file, and the Administrator was unable to locate the DHS work letter. The facility's policy stated that background checks would be completed and individuals with a history of abuse, neglect, or misappropriation would not be employed, but this procedure was not followed in this instance.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Revise and Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise care plans for two residents as required. For one resident with a history of cancer, anxiety, depression, psychotic disorder, spinal stenosis, and dysphagia, the care plan did not accurately reflect the resident's current status regarding the use of a feeding tube at night and supervised oral intake. The care plan contained outdated interventions, such as indicating the resident was independent with eating and NPO, despite changes in the resident's condition and physician orders. Staff interviews confirmed that the care plan should match the resident's current needs and abilities, and the facility's policy required updates to the care plan upon a change in condition. For another resident with moderate cognitive deficits, serious mental illness, and a legal guardian, the care plan failed to include goals and interventions related to the resident's ongoing sexual relationship with another resident. Although the care plan noted the existence of a sexual relationship, it lacked specific interventions or goals to address this issue. The administrator acknowledged that such information should be included in the care plan. These deficiencies were identified through observations, staff interviews, clinical record review, and policy review.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, nor does it mention particular residents or their medical conditions at the time of the deficiency.
Failure to Provide Bathing per Resident Preference and Care Plan
Penalty
Summary
A deficiency occurred when a resident with paraplegia and significant self-care deficits did not receive bathing services according to their preferences and care plan. The resident, who was totally dependent on staff for hygiene and transfers, was only provided bed baths because staff believed he lacked the trunk support necessary to use a shower chair. Staff were unfamiliar with the use of a shower bed, which was only located and utilized after a significant period. Documentation showed that the resident received only one shower over several weeks, with multiple gaps where showers were not offered or documented, and some refusals not followed up with additional offers. The resident expressed a desire for a real shower at least once a week, but staff continued to provide only bed baths until the shower bed was found. The facility's policy required staff to assist with bathing to promote cleanliness and dignity and to notify the charge nurse of refusals, but records indicated inconsistent documentation and lack of regular shower offers. The resident's medical history included neurogenic bladder, paraplegia, recurrent hip dislocation, pressure ulcer, insomnia, and adult failure to thrive, and he was totally dependent on staff for all ADLs.
Failure to Complete Required Neurological Assessments After Resident Fall
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 4, and multiple diagnoses including non-Alzheimer's dementia, hypertensive urgency, pneumonia, adult failure to thrive, and dysphagia, experienced a fall in her bedroom after attempting to transfer from bed to the commode. The care plan for this resident identified her as being at risk for falls and included specific interventions such as not leaving her alone on the toilet/commode, keeping walkways clear, and applying nonskid strips. Despite these interventions, the resident was left alone and subsequently fell while transferring. Following the fall, the facility's protocol required a licensed nurse to perform neurological evaluations at specified intervals over a 72-hour period, with documentation on a Neurological Evaluation Form. However, staff failed to complete and document several required neurological assessments at multiple scheduled times. The Interim DON confirmed that the neurological checks were not performed as required, and the clinical record review showed missing entries for the mandated assessments.
Failure to Protect Residents from Abuse and Inappropriate Use of Media
Penalty
Summary
Staff D's employee file included a signed document acknowledging the rights of residents to be free from abuse, neglect, misappropriation of property, exploitation, corporal punishment, involuntary seclusion, and unauthorized use of physical or chemical restraints. The facility's policies prohibit staff from taking or distributing photographs or recordings of residents in any manner that could demean or humiliate them, including sharing such content on social media or through multimedia messages. The employee handbook further restricts the use of personal cell phones while on duty and emphasizes the importance of maintaining resident confidentiality and dignity in all communications, including online activity. The facility also maintains a policy requiring a media release form to be signed by residents for any photographic or video recordings, specifying the intended use and allowing residents to revoke authorization at any time. Despite these documented policies and procedures, the report indicates a deficiency related to the protection of residents from all forms of abuse, including the inappropriate use of photographs or recordings, suggesting that the facility's practices or staff actions did not fully align with established protocols to safeguard resident rights and privacy.
Failure to Monitor and Document Catheter Output for High-Risk Resident
Penalty
Summary
The facility failed to consistently monitor and document urine output for a resident with a suprapubic catheter who was at risk for urinary tract infections. The resident, who had diagnoses including neurogenic bladder, paraplegia, and adult failure to thrive, was totally dependent on staff for care and had a physician order requiring staff to record catheter output per shift and monitor for signs and symptoms of infection. Despite this, review of the Medication and Treatment Administration Records showed that urine output was only documented once on three separate days in June, and there was no documentation of urine output from June 24th to June 30th. Additionally, the Point of Care Response History lacked documentation of urine output for a full week in July. Staff interviews revealed inconsistent practices regarding urine output monitoring, with a nurse consultant stating that output was not monitored on all catheters unless there was a physician order or the resident was considered high risk, despite the presence of such an order for this resident. The resident had previously been admitted to the hospital with septic shock, and facility policy and nursing references indicated the importance of monitoring urine output and promptly reporting abnormal changes. The lack of consistent monitoring and documentation represented a failure to follow physician orders and established care protocols for residents with urinary catheters.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the resident's well-being. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Implement Infection Control and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices involving three residents with indwelling medical devices and wounds. For one resident with a suprapubic catheter, the catheter bag was observed lying on the floor while the resident was in bed, which was acknowledged by facility leadership as inappropriate placement. Another resident with a gastrostomy tube and wounds was observed during care where the registered nurse inconsistently performed hand hygiene, failed to use a gown as required by Enhanced Barrier Precautions (EBP), and did not maintain a clean environment when handling supplies and performing dressing changes. The nurse also failed to use a barrier for clean supplies and did not consistently change gloves or perform hand hygiene between clean and dirty tasks. A third resident, who was totally dependent on staff for hygiene and had an indwelling urinary catheter and wounds, received personal incontinence care from two certified nurse aides. During this care, the staff did not wear gowns as required by EBP, and the resident's catheter bag was placed on the bed during the procedure. Facility policy required the use of gown and gloves for high-contact care activities involving indwelling devices and wounds, but these protocols were not followed during the observed care events. Interviews with facility leadership confirmed that the observed practices did not meet the facility's expectations or policy requirements for infection control, hand hygiene, and EBP. The facility's own policies, as well as posted signage, specified the need for gown and glove use during high-contact care for residents with indwelling devices or wounds, and for proper hand hygiene before and after glove use and care activities. These deficiencies were identified through direct observation, record review, and staff interviews.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to implement appropriate infection control practices during an active COVID-19 outbreak, as observed by surveyors. Upon entry, a sign indicated that all visitors must wear masks due to COVID-19, yet several staff members and residents were observed not adhering to this protocol. Staff A, a Dietary Cook, walked through the facility without a mask, passing by residents who were also not wearing masks. Additionally, Staff F, a Pharmacy Consultant, was seen without a mask in the Supply Room, and Staff G had to educate them on keeping the door closed if not wearing a mask. The facility had 14 rooms designated as COVID-19 positive, with PPE available outside each door. However, only a few residents were observed wearing masks, and only one wore it correctly. Staff interviews revealed that there was a shortage of N95 masks, leading some staff to double up on surgical masks when entering COVID-19 positive rooms. Despite the outbreak status, there was no signage at the entrance indicating the facility's outbreak status or mask recommendations. Staff interviews confirmed that the facility had been in outbreak status since 12/16/24, with 22 residents and 9 staff testing positive for COVID-19. The outbreak was traced back to a staff member, and there had been one hospitalization but no deaths. Staff were aware of the requirement to wear masks and PPE when entering COVID-19 positive rooms, but there was inconsistency in adherence to these protocols. The facility's policies referenced CDC guidelines for infection control, but these were not effectively implemented during the outbreak.
Inaccurate PBJ Staffing Report Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period of April 1 to June 30. The report, run on November 13, 2024, indicated excessively low weekend staffing and resulted in a one-star staffing rating. Upon review, it was found that the facility maintained equal staffing levels during the week and weekends, contrary to what was reported. The Administrator acknowledged the inaccuracy in the PBJ report and stated that the facility followed the per patient day (PPD) formula defined in the facility assessment for staffing numbers, with no changes made for weekend staffing.
Infection Control Deficiencies in Resident Care and Facility Operations
Penalty
Summary
The facility failed to implement appropriate hand hygiene and infection control practices during resident care, medication administration, and laundry delivery. Resident #48, who had multiple medical conditions including septicemia and a pressure ulcer, did not have signage indicating the need for enhanced barrier precautions (EBP). During wound care, staff members did not consistently perform hand hygiene when changing gloves, which is against the facility's policy and CDC guidelines for infection prevention. In addition to the issues with resident care, there were multiple observations of improper hand hygiene during medication administration by various staff members. Staff members were observed handling medications with bare hands, failing to perform hand hygiene before and after glove use, and improperly managing spilled medications. These actions were contrary to the facility's medication administration policy, which requires hand sanitization between tasks and proper handling of medications. The facility also failed to maintain proper infection control practices during laundry delivery. Staff were observed carrying uncovered laundry close to their faces and allowing it to touch the floor, which is against the facility's policy for handling linen and laundry. The policy requires that clean laundry be covered during transport to prevent contamination. These deficiencies highlight a lack of adherence to established infection control protocols, potentially increasing the risk of pathogen spread within the facility.
Facility Fails to Provide Resident Access to Personal Funds
Penalty
Summary
The facility failed to provide residents with access to their personal funds managed by the facility, as evidenced by interviews with residents and staff, and a review of facility policies. Resident #4, with no cognitive impairment, reported that he could only obtain money during the business office hours, which were limited to 9 am to 2 pm, Monday through Friday. This restriction meant that residents could not access their funds at night or when the business office was closed. Similarly, Resident #21, also with no cognitive impairment, confirmed that money was kept in a safe by Staff K, and if neither Staff K nor the Administrator was present, residents could not access their funds. Staff interviews further corroborated the issue, with Staff L, an RN, stating that cash was not available in the evenings or on weekends when Staff K was not present. Staff F, an LPN, mentioned discussions about making a lockbox available for weekends and overnights, but this had not been implemented. Staff K, the Business Office Manager, acknowledged that residents did not have access to their funds unless she was working and mentioned a plan to prepare funds in advance for residents. However, grievances had been filed by residents due to the unavailability of funds, and the facility had not yet finalized a policy to address this issue. The facility's policy review revealed that residents should have access to their funds during normal banking hours and be able to make withdrawals at any time. However, the current practice did not align with this policy, as residents were unable to access their funds outside of limited hours when specific staff were present. The Administrator admitted that there was no access to personal funds on weekends or evenings when she or Staff K were not at the facility, and acknowledged grievances related to this issue. The facility was in the process of developing a new policy but had not yet implemented it.
Failure to Maintain a Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable environment for its residents, as evidenced by observations of missing or damaged floor tiles in the north hall. Despite the facility's census of 51 residents, the necessary repairs were not completed over several days. The Maintenance Director acknowledged responsibility for minor repairs, including floor tile repair, but could not provide a reason for the delay in addressing the issue. Maintenance rounds were reportedly conducted monthly, and cosmetic repairs were logged in a facility application accessible to all staff. However, there were no unresolved building repairs noted in the system. Additionally, the Corporate Director of Operations confirmed the absence of a specific policy for maintaining a homelike environment or addressing maintenance repairs.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at a safe and appetizing temperature during meal service. On the morning of November 20, 2024, a cook checked the temperature of the breakfast sausage gravy, which was initially recorded at 180°F. An hour later, the temperature of the same item had dropped to 130°F. The Dietary Manager indicated that staff are expected to check food temperatures before, during, and after meal service to ensure compliance with regulatory standards. However, the Corporate Director of Operations acknowledged that the facility lacked a specific policy regarding holding temperatures for meal service.
Deficiencies in Food Storage, Labeling, and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food storage, labeling, and sanitation practices, as observed during a survey. A Registered Nurse (RN) was seen using a hand hygiene sink to fill a pitcher of water for resident use, which is against the facility's policy. Additionally, the kitchen contained several unlabeled food items, including a package of pink meat and a tan pitcher of liquid in the refrigerator, as well as two clear bags of multicolored items in the pantry. These observations indicate a lack of compliance with the facility's policy that requires all food items to be dated and labeled. Furthermore, the facility did not maintain the appropriate concentration of sanitizer solution for food preparation surfaces. A dietary aide documented a sanitizer concentration of 100 parts-per-million (ppm), which is below the manufacturer's recommended 200 ppm for effective sanitation. The facility's policies, including those on nutritional services sanitation and hand hygiene, were not followed, contributing to the deficiencies observed. The Dietary Manager confirmed that staff should not use the hand hygiene sink for non-hand hygiene purposes and that sanitizer solutions should be prepared fresh before each meal service.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately assess and document the medical status of three residents during the observation period of the Minimum Data Set (MDS). For Resident #25, the MDS inaccurately documented the use of anticoagulant therapy, while the Medication Administration Record (MAR) showed a prescription for clopidogrel bisulfate (Plavix), an anti-platelet, not an anticoagulant. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the error, noting a misunderstanding of the medication classification. Similarly, Resident #32's MDS incorrectly recorded insulin therapy, although the MAR indicated a prescription for Trulicity, a non-insulin medication. The ADON confirmed that Resident #32 had never been on insulin, and the MDS was coded incorrectly. For Resident #48, the MDS inaccurately documented the use of an external catheter, while the care plan and MAR indicated the use of an indwelling catheter due to a diagnosis of neurogenic bladder. The DON and Regional Nurse Consultant confirmed the error, stating that the care plan was correct, but the MDS was not. The facility's policy requires the MDS to be completed using direct observation, communication, and medical record documentation, which was not adhered to in these cases.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to provide a comprehensive care plan for two residents, leading to deficiencies in addressing their specific medical needs. Resident #25, who had no cognitive impairment, was prescribed clopidogrel bisulfate (Plavix), an anti-platelet medication. However, the resident's care plan did not include any focus, goals, or interventions related to the use of this medication, which is essential for managing the risk of bleeding. The Director of Nursing (DON) acknowledged the absence of a care plan addressing the anti-platelet therapy, despite the facility's policy requiring a person-centered care plan for each resident. Resident #48, with moderate cognitive impairment, had multiple diagnoses including septicemia, multiple sclerosis, and a pressure ulcer, among others. The resident's care plan lacked documentation for enhanced barrier precautions (EBP), which are crucial for infection control, especially given the resident's indwelling catheter and pressure ulcers. The DON confirmed that the need for EBP should have been noted in the care plan, indicating a lapse in the facility's adherence to comprehensive care planning for residents with complex medical needs.
Failure to Ensure Safe Wheelchair Use for Residents
Penalty
Summary
The facility failed to protect residents from potential accidents and injuries, as observed in the cases of two residents. Resident #8, who has normal cognitive function and requires substantial assistance, was observed being pushed in a manual wheelchair without foot pedals by a Certified Nursing Assistant (CNA). The CNA, who was a contract staff member, stated that she had not received training from the facility regarding the use of wheelchairs and transfers. This action was contrary to the resident's care plan, which required the use of a Hoyer lift for transfers. Resident #15, who has severe cognitive impairment and can self-propel a wheelchair with setup assistance, was also observed being pushed without foot pedals by a Licensed Practical Nurse (LPN). Additionally, the resident was seen self-propelling the wheelchair within the facility. Staff interviews revealed that the facility's expectation was for foot pedals to be used when pushing residents in wheelchairs, and this had been communicated through training. However, the facility did not have a specific policy regarding the use of foot pedals, relying instead on Standards of Practice.
Failure to Provide Accurate and Timely Assessments and Interventions
Penalty
Summary
The facility failed to provide accurate and timely assessment and interventions for several residents. For Resident #3, the staff did not obtain a physician's order for home medications upon discharge. The LPN was instructed by the Administrator to send leftover medications, including narcotics, with the resident without proper authorization. The Nurse Practitioner confirmed that she would never authorize sending narcotics home without a separate prescription, and the facility policy required a prescriber's order for discharge medications, which was not followed in this case. Resident #4 experienced a fall and reported dizziness and hitting her head. However, the chart lacked a complete assessment, including neurological checks and a full body assessment after the unwitnessed fall. The DON and ADON acknowledged the absence of an incident report and necessary assessments, which were expected per facility policy. The resident later reported that staff did not check her head or body for injuries after the fall. For Residents #2 and #9, the facility failed to notify the physician of high and low blood glucose levels as required. Both residents had multiple instances of blood glucose readings outside the specified parameters, but the nursing notes lacked documentation of physician notification. The DON initially thought the notification threshold was a mis-entry but later confirmed the correct parameters. The NP noted inconsistent communication between the facility and providers, which hindered timely follow-up and appropriate orders.
Inadequate Discharge Planning for Multiple Residents
Penalty
Summary
The facility failed to ensure adequate discharge planning for four out of five residents reviewed. Resident #1 was discharged without proper coordination of home medications, leading to a delay in receiving essential medications. The resident's family was unprepared for the discharge, and the facility did not ensure that the necessary follow-up appointments and home health services were arranged. The resident experienced adverse symptoms due to the lack of timely medication access. Resident #3 was discharged without sufficient insulin and other necessary medications. The facility did not provide the resident with a complete medication list or ensure that the pharmacy had the proper paperwork to dispense the medications. The resident's blood glucose levels became dangerously high, requiring emergency medical intervention. The home health nurse had to arrange for the resident to see a doctor and obtain the needed medications. Resident #6 was discharged without home health services, follow-up appointments, or prescriptions. The resident's daughter was forced to take him home due to financial constraints, and the facility did not complete the necessary discharge paperwork or medication list. Similarly, Resident #4 was discharged without prior notification to the family and without arranging home health services. The resident experienced a fall shortly after discharge and was readmitted to another facility. The facility's failure to coordinate discharge planning and ensure continuity of care led to significant issues for the residents involved.
Failure to Follow Proper Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to follow standard infection control practices related to proper hand hygiene for one of the three residents reviewed. During incontinence care for a resident, two CNAs did not change their gloves or perform hand hygiene after cleaning the resident's legs and buttocks. The CNAs continued to use the same gloves while putting on a clean brief, pulling up the resident's pants, and handling the mechanical lift. One CNA removed her gloves but did not use sanitizer, while the other CNA did not change her gloves at all. The resident involved had a BIMS score of 14, indicating intact cognitive ability, and required substantial assistance with dressing, hygiene, and was totally dependent on staff for toileting and bathing. The resident had multiple diagnoses, including anemia, coronary artery disease, heart failure, renal insufficiency, diabetes mellitus, and a cerebrovascular accident. At the time of the incident, the resident was on an antibiotic for acute cholecystitis. The facility's hand hygiene policy, last reviewed on 4/28/22, indicated that hand hygiene should be performed following clinical indications, including before and after providing care and contact with blood, body fluids, or contaminated surfaces.
Failure to Notify Resident Representatives After Falls
Penalty
Summary
The facility failed to notify resident representatives after falls for two residents. Resident #6, who had moderate cognitive deficits and required assistance with daily activities, fell while pushing another resident in a wheelchair. Although the incident report indicated that the Director of Nursing (DON) and Assistant Director of Nursing (ADON) notified the physician, there was no documentation of family notification. A family member confirmed that they were unaware of the fall incident. Resident #4, who had intact cognitive ability and required substantial assistance with mobility and personal hygiene, reported a fall to staff after getting dizzy and hitting her head. The emergency contact for Resident #4 stated that they were not informed about the fall. The DON and ADON assumed the representative was informed during the resident's discharge, but the chart lacked a neurological or full body assessment after the unwitnessed fall. The facility's policy required notifying the physician and resident representative of any change in condition, including accidents or incidents.
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A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Two residents who were cognitively impaired and dependent on staff for personal care did not receive bathing assistance at least twice weekly as required by facility policy. Facility records showed multiple instances where bathing was documented as refused or not applicable, resulting in gaps of 6, 7, and 11 days between baths. The care plan for one resident specified total dependence on staff for bathing, and the facility’s policy required showers to be offered at least twice weekly and on the next available day if missed. The DON reported that staff are expected to continue offering showers and try different approaches after refusals, but the documented bathing intervals did not reflect this practice.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
A resident with COPD, pneumonia, and respiratory failure was transferred to the hospital for acute respiratory distress and later deemed medically ready for discharge, but the facility delayed readmission by three days due to staffing and admission timing practices. Facility staff, including an RN, MDS coordinator, ADON, DON, and Administrator, reported that they avoided weekend and evening admissions, required two nurses for admissions, and were concerned about entering medication orders into the EMR in time for pharmacy delivery when only one nurse was on duty. They did not notify the provider about the planned discharge back, did not arrange alternative pharmacy or transport options, and cited shared transport and lack of additional nurses as reasons the readmission was not feasible, despite the facility’s stated commitment to 24-hour nursing care and medication management.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
Failure to Provide Twice-Weekly Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance at least twice weekly, as required by its own policy, for two residents who were dependent on staff for bathing. For one resident with anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive impairment, the MDS documented total dependence on staff for bathing. Facility documentation showed that bathing was recorded as refused on one date, with actual baths provided on dates that resulted in a 6‑day interval without a bath on two separate occasions. The resident’s care plan indicated the resident was totally dependent on staff to provide a bath as necessary. For another resident with diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, facility records showed multiple dates where bathing was documented as refused or as not applicable. Review of the Follow Up Question Report demonstrated several extended gaps between baths: 6 days on two occasions, 7 days on one occasion, and 11 days on another, despite the facility policy requiring showers to be offered at least twice weekly and, if missed, to be offered on the next available day. In an interview, the DON stated that when a resident refuses a shower, staff are expected to continue to offer, try multiple times, try a different person, and continue to try the next day until the resident bathes, which was not reflected in the documented bathing intervals for these two residents.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Delayed Hospital Readmission Due to Insufficient Nursing Staff and Admission Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and related processes to support the timely readmission of a hospitalized resident, resulting in a three-day delay in the resident’s return. The resident had moderately impaired cognition, with a BIMS score of 12/15, and medical diagnoses including COPD with acute exacerbation, pneumonia, and respiratory failure. The resident was transferred to the hospital after staff observed labored respirations, use of accessory muscles, diaphoresis, an oxygen saturation of 85% on room air, and wheezing, with improvement after oxygen was applied but continued labored breathing. Hospital records show the resident was admitted and later determined medically stable and ready for discharge, with documentation that the patient was planned for discharge but was not accepted back to the facility due to timing issues and would remain in the hospital over the weekend. Hospital progress notes documented that the resident was medically ready for discharge and that discharge was planned but not completed because the facility would not accept the resident later in the day. A hospital case management/social work note indicated confirmation that the facility could take the patient on the day the resident ultimately returned. The facility’s EHR showed the resident’s billing status changed to STOP BILLING on the date of hospital transfer and back to active several days later, corresponding to the delayed readmission. The resident reported spending three days in the hospital before being able to return to the facility. Multiple staff interviews described facility practices that contributed to the delay in readmission. An RN stated the facility tried not to do admissions on weekends and did not want admissions after 2 p.m. so nurses could complete admission tasks and enter medications into the computer in time for pharmacy delivery. The MDS Coordinator stated the facility liked residents readmitted before 2 p.m. to obtain medications, that the hospital had informed them the resident would not return until early evening, and that the facility needed two nurses in the building for an admission; the coordinator also stated the facility did not do admissions on weekends and was unsure about using another pharmacy or family to obtain medications. The ADON and DON both stated that with only one nurse on duty, a readmission later in the day was not feasible due to the time needed for admission assessments and medication entry, and they cited concerns about not having medications on time and the workload of one nurse caring for existing residents and completing a readmission. The DON further stated the facility did not accept evening or Saturday admissions for safety reasons, did not notify the provider about the planned discharge back to the facility, and did not explore hospital-supplied medications or alternative transport options, while acknowledging the presence of on-call nurses. The Administrator confirmed that with only one nurse, a readmission was considered not doable. The facility lacked written transportation or readmission policies and relied on general CMS and Resident Rights guidance, while its Resident Handbook stated residents receive individualized 24-hour nursing care and medication management.
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