Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Acres Rehabilitation And Care Center during CMS and state inspections, most recent first.
A facility failed to complete comprehensive nursing assessments and interventions for multiple residents with significant changes in condition, including falls, ER/hospital returns, altered mental status, pneumonia treated with antibiotics, nausea and vomiting, rib fractures, and skin injury. One resident had an unwitnessed fall with head/facial injury, limited neuro checks, missing nursing documentation, and later returned to the hospital with altered mental status and hypothermia before dying with sepsis listed as the cause of death. Other residents also lacked documented assessment and follow-up after acute decline, medication treatment, or injury.
A facility failed to prevent and treat pressure injuries for multiple residents with high skin-risk needs. One resident who was wheelchair dependent, incontinent, and on hospice developed a facility-acquired Stage 4 pressure sore after pressure-relief equipment was not used appropriately and repositioning/incontinence care were not provided consistently. Another resident with a Stage 4 hip wound and heel ulcers did not receive ordered protective boots and was exposed to friction and shear during incontinence care, and a third resident did not receive proper heel care or prevention for the opposite heel. Surveyors identified the issue as Immediate Jeopardy.
A resident with fractures, wounds, oxygen needs, and hospice admission had severe pain, agitation, and distress after being found tipped forward in a recliner with a new arm wound. Family reported delayed nurse response, and the chart showed gaps in pain assessment, unclear follow-up after the incident, and delayed implementation of a new morphine order because the e-script was not received correctly by the pharmacy. Grievances from other residents also described pain meds not being given timely or being unavailable, with incomplete follow-up documentation.
A resident with intact cognition and dependence for transfers was bruised during rolling and bed mobility when staff reportedly held his arms too hard, with deep purple bruises documented on the wrist/hand and elbow and photos showing finger-mark-like lines. The record also included repeated concerns about rude or intimidating staff interactions, incomplete abuse investigations, and delayed ADL and incontinence care for other residents.
Unsafe Smoking Supervision and Missing Smoking Assessments: Multiple residents with cognitive and physical impairments had outdated or missing smoking assessments, and residents who required supervision or smoking aprons were observed smoking without those protections. Staff were unable to maintain supervision in the smoking area, and one resident sustained a thermal burn when a cigarette cherry fell into a shoe.
Repeated resident complaints, grievance reports, and staff interviews showed that call lights were often answered late, residents were left wet or soiled, and assistance with toileting, showers, meals, and other ADLs was delayed. Residents reported waiting 30 minutes to 2 hours for help, being turned away after pressing the call light, and not receiving timely incontinence care. An observation also found a resident left in a hospital gown for hours without grooming, dressing, oral care, position changes, or incontinence care, while staff described difficulty meeting heavy care needs with limited aide coverage.
The facility failed to update its facility assessment to reflect recent changes in DON, MDS Coordinator, and Administrator leadership, as well as current resident care needs. The assessment understated the number of residents needing transfer and toileting assistance and did not match the roster showing many residents required assist of 1, assist of 2, EZ sit-to-stand lifts, or Hoyer lifts, with most residents incontinent. The assessment also did not reflect the number of residents on EBP observed during the survey, and the Administrator signed the review as needing no changes.
Infection control and EBP were not followed for multiple residents with MDROs, catheters, wounds, and incontinence needs. Staff were observed entering rooms without required PPE or EBP signage, changing gloves without hand hygiene, handling soiled briefs, linens, and equipment with contaminated gloves, and failing to cleanse all areas during personal care and wound care. The facility also lacked tracking records for facility-wide infection control and antibiotic stewardship, and laundry handling practices were not maintained appropriately.
Failure to Provide Timely ADL and Incontinence Care: Residents with significant cognitive and physical impairments were repeatedly left waiting for help with toileting, incontinence care, grooming, oral care, transfers, and showers. Grievances and observations showed call lights going unanswered, residents remaining wet or soiled for long periods, missed or delayed showers, and staff providing incomplete personal care, including incomplete cleansing after bowel and bladder incontinence and skipped oral care.
Failure to provide restorative nursing programs for residents with mobility needs. Four residents with varying cognitive and physical impairments had MDS assessments showing no restorative nursing program participation, and their care plans lacked restorative nursing programs despite documented mobility concerns, ROM needs, wheelchair use, ambulation assistance, and therapy-to-nursing maintenance plans. Staff interviews described reliance on informal communication, Kardex notes, and therapy handoffs, while CNAs reported they had not received facility training on individualized restorative therapies beyond basic CNA instruction.
Staff failed to demonstrate competency in infection control, EBP, and incontinence care, with CNAs observed entering rooms without proper PPE, skipping hand hygiene, and providing incomplete cleansing during personal care. An RN also could not accurately describe a resident’s baseline or current condition after a rash progressed to hypotension and sepsis, and another resident’s G-tube orders were inconsistently communicated and transcribed.
A resident with intact cognition and significant assistance needs for toileting and transfers was left waiting for help to use the restroom after requesting assistance during medication pass. An LPN left to find help, and later a CNA entered the room, turned off the call light, shrugged, and walked out without assisting. The resident reported waiting over 2 hours to have a bowel movement and felt abandoned due to short staffing.
A resident with intact cognition, debility, and cardiorespiratory conditions had a stated preference to shower at 11:00 AM on Tuesdays, but staff prepared him for a shower around 7:00 AM instead. The care plan did not identify his bathing-time preference, and during the shower-room observation a CNA interrupted him and spoke in an argumentative manner as he explained that staff told him it was time to wake up and shower.
A facility failed to timely report two abuse-related events to DIAL: one resident with intact cognition developed an unexplained rib fracture after worsening pain and ER evaluation, and another cognitively intact resident had bruising to the wrist and elbow after stating staff grabbed him too hard during care. The records showed internal documentation and resident statements, but no timely abuse/unknown-origin reporting to the state agency.
Incomplete Abuse and Injury Investigations: The facility did not complete thorough investigations for a resident with patterned bruising after care and turning, another allegation involving a CNA’s intimidating and harsh interaction with the resident, and a second resident with an unexplained rib fracture. The records showed the resident reports, staff observations, and limited investigation notes, but the file lacked a full abuse investigation, including a surveyor statement and complete follow-up on staff statements describing harsh or verbal abuse.
A resident with severe cognitive impairment, stroke-related deficits, dysphagia, and G-tube dependence had feeding orders that were held, extended, and later resumed in a way that was not clearly reflected in the EHR. An RD recommended holding the tube feed, and later extending the hold, but an LPN reported he could not find a clear order showing the feeding remained on hold or was discontinued. Observation found Osmolite and water flush supplies still set up in the room, and the record later showed a further RD recommendation to discontinue the G-tube feedings and flushes had not been documented as communicated to or reviewed by the provider.
Two medication management failures were identified. One resident with diabetes and intact cognition did not receive ordered mealtime insulin on two occasions because staff misread the order as a duplicate, and the DON confirmed the nurse should have verified and administered it as ordered. Another resident with a history of DVT and PE continued to have Xarelto listed on the MAR after a hospital stay for vaginal bleeding in which the anticoagulant had been discontinued; the resident repeatedly refused it, and the order remained active until later review by the physician and NP.
Failure to post current daily staffing information in a public location was identified. Observation found the staffing sheet near the east entrance was hard to read, kept with multiple outdated forms, and did not show a current daily posting; staff said the schedule was in the breakroom, and the Administrator provided hall assignment sheets that did not include the total number or actual hours worked by nursing staff.
Unlocked medication and supply carts were observed left unattended in resident hallways with medications inside, including duloxetine, Baclofen, trazadone, and Eliquis. Staff were seen near the carts but did not secure them right away, and both an LVN and an RN stated the carts should be locked when left unattended. The facility policy required all drugs and biologicals to be stored in locked compartments and kept locked unless under direct observation during a med pass.
Palatability of Served Sandwiches: Dietary staff served ham and cheese sandwiches that became hard and dry during meal service. A test tray from the 100 hall showed the bun was very hard and difficult to cut, and residents reported the bread was hard, did not taste good, or was gross. The Dietary Supervisor noted the buns looked hard when removed from the oven and believed the time in the oven may have dried them out.
Unattended EHR Laptop Exposed Resident Information: An EHR laptop was left open on a resident hall with 11 residents' information visible. An RN stated laptops are not to be left open when staff are not present and said he did not know it was open. The DON stated the screen should be locked when staff walk away, and the facility's HIPAA Security Measures policy required physical safeguards to limit access to electronic information systems.
Staff failed to maintain resident dignity and respond appropriately to needs in several instances. A resident with chronic pain and a leg fracture was left on the toilet for an extended period after activating the call light, despite multiple staff reportedly walking past without responding, and later reported that an LPN was intimidating and did not provide requested PRN narcotic pain medication for severe pain, leading the resident to cry in pain. Two residents reported that staff routinely entered their rooms without knocking, which was directly observed when staff interrupted interviews without announcing themselves. Another dependent resident with CVA, malnutrition, aphasia, dementia, and severely impaired cognition was observed being fed by a CNA who appeared disengaged, did not interact with the resident, mechanically placed food and a straw into the resident’s mouth, and rubbed her eye before continuing to feed, contrary to expectations for dignified, respectful care.
Surveyors found that the facility failed to fully incorporate key interventions into the comprehensive care plans for two residents. One resident with a history of stroke, unsteadiness, and a recent fall from bed had been instructed by staff to keep the bed in the lowest position while asleep, but this specific fall-prevention measure was not documented in the care plan, which only referenced general mobility assistance and a clutter-free environment. Another resident with severe cognitive impairment, dementia with behavioral disturbances, anxiety, and depression had an active order for antianxiety medication and documented anxiety behaviors, yet the care plan did not list the antianxiety medication, did not describe the target anxiety behaviors for staff to monitor, and did not include non-pharmacologic interventions for anxiety management.
Staff failed to protect a resident’s heels during a mechanical lift transfer and did not provide required supervision for an at-risk smoker. One resident with impaired cognition, bilateral leg weakness, stroke history, and a moderate Braden risk was observed being transferred from bed to wheelchair in a mechanical lift by an OT and a CNA, during which his heels were dragged across the mattress and later noted to be red, contrary to staff statements and facility policy that feet should be elevated and not contact the mattress during active movement. Another resident with hemiplegia, stroke, and other comorbidities had documentation and a care plan stating he was not an independent smoker, lacked spatial and self-awareness, and required supervised smoking, yet he was able on separate early mornings to wheel himself to the enclosed courtyard, cancel or trigger the door alarm, and access the smoking area without staff present, despite a policy requiring supervision per the care plan.
Facility staff did not consistently respond to resident call lights within a reasonable time, especially during evening and night shifts. Several cognitively intact residents reported waiting 30–45 minutes for assistance with toileting and personal care, with one resident left on the toilet for an extended period and another going to bed without proper hygiene. A resident also described a prolonged delay in response while choking on mucous. Resident Council minutes documented concerns about long call light wait times, staff turning off call lights, and staff wearing earbuds during care. Although the DON and CNAs stated that call lights should be answered promptly and the written policy required all staff to respond to activated call lights, these expectations were not consistently met.
A resident with multiple chronic conditions and intact cognition received another resident’s medications after a CMA pre-poured meds for several residents, left them on the med cart, and handed responsibility to a trainee CMA who did not follow the 6 rights of medication administration or verify identity using the MAR. The trainee, unaware that a new resident shared the same room and lacking a photo in the EHR for comparison, administered a muscle relaxant, anticonvulsant, anti-anxiety, and antihypertensive intended for someone else. The resident reported being told the pills were hers despite voicing concern, then blacked out, fell from a scooter, developed hypotension and bradycardia, and required ICU admission with medication and intermittent vasopressor support.
Failure to follow physician orders occurred when a resident with depression, anxiety, toxic encephalopathy, and impaired cognition had quetiapine orders entered and administered inconsistently, with scheduled dosing not transferred correctly and PRN use documented instead. The resident had escalating behaviors, including grabbing a fire extinguisher, shredding a roommate’s pillow, increased anxiety, refusal to speak with staff and the psych provider, and later transfer to the hospital for altered mental status and unsafe behaviors.
A resident with a suprapubic catheter, impaired cognition, and multiple diagnoses including quadriplegia and abnormal bladder function was receiving perineal care when a CNA lifted the urinary drainage bag above the bladder while dressing him. Urine in the tubing, including a white mucoid substance, flowed back into the bladder. The CNA stated she knew the bag and tubing should not be higher than the resident, and the DON confirmed staff should not have raised the drainage bag above bladder level.
Failure to administer a pneumococcal vaccine after consent was obtained. A resident with cancer, sepsis, respiratory failure, and a hx of pneumonia was admitted with immunization status listed as not up-to-date and vaccine past due. The EHR showed consent for Prevnar 20, but the record lacked documentation of prior PPSV23 or other pneumococcal conjugate vaccines, and progress notes did not show the vaccine was given. The ADON/IP stated the order was entered but not marked yes and was on the MAR but not administered.
Failure to Administer Consented COVID-19 Vaccine: A resident with sepsis and non-Alzheimer’s dementia consented to receive the COVID vaccine, but the EHR showed only an older COVID booster and no documentation that the requested vaccine was ever given. The ADON/IP stated the facility had standing immunization orders, checked the IRIS registry, and offered flu and pneumonia vaccines, but had not gotten to COVID immunizations.
A resident with COPD, HF, and DM had repeated signs of decline, including lethargy, poor intake, altered MS, and possible facial droop, but staff did not timely document or escalate the change before the resident was sent out and later diagnosed with sepsis and organ failure. In a separate issue, a resident with bipolar disorder and memory impairment had 30-day psychotropic orders entered on admission, but the provider was not timely notified to clarify the stop dates even after the pharmacy flagged the orders, and the meds were stopped without tapering before being restarted.
Failure to Remove Old Fentanyl Patch Before New Application: A resident with cancer, COPD, and chronic pain had a fentanyl patch ordered every 3 days with instructions to remove the old patch before applying a new one. Records showed a new patch was applied while an old patch remained in place, and the resident later became lethargic and confused, was sent to the hospital, and had two fentanyl patches removed during EMS/ED care. The hospital course documented ICU transfer for fentanyl overdose with severe acute hepatic encephalopathy.
Surveyors found the facility failed to maintain a safe, clean, and comfortable environment, with observations of stained carpets, peeling paint, water damage, dust buildup, and soiled resident equipment. A resident's wheelchair was dirty, had a broken wheel lock, and showed signs of neglect. Facility staff and the DON confirmed these issues, and facility policy required a higher standard of cleanliness and maintenance.
Multiple residents with significant care needs, including those with morbid obesity, heart failure, stroke, and hemiplegia, experienced excessive delays in staff responding to call lights, sometimes waiting over an hour or more. Residents described staff turning off call lights and not returning, and observations confirmed that call lights were not always accessible. The DON stated the expectation was a 15-minute response, but this was not consistently met, resulting in unmet care needs and residents seeking help on their own.
Staff failed to follow infection control protocols during resident care and meal assistance, including not changing gloves or performing hand hygiene between residents, improper handling of catheter drainage equipment, and inadequate use of PPE during care for residents with MDROs. Supplies of gowns for enhanced barrier precautions were also found to be insufficiently stocked.
A resident with stroke, dementia, and hemiplegia who was fully dependent on staff for toilet hygiene did not receive complete incontinence care. During observed care, staff failed to cleanse the inner thighs, outer buttocks, and hips as required by facility policy, despite removing a wet brief and cleansing other areas. The DON confirmed that all areas should have been cleansed.
Staff were observed repeatedly failing to perform hand hygiene while serving food and drinks, handling utensils, and feeding residents by hand, as well as not cleaning shared equipment between resident uses. These actions did not follow facility infection control policies and created unsanitary conditions during meal service and equipment use.
The facility experienced repeated deficiencies in areas such as care plan development, accident prevention, and infection control due to an ineffective QAPI process. Multiple surveys found ongoing failures to update care plans for residents with specific medical needs, ensure proper supervision for those at risk of accidents, and maintain infection prevention standards. Despite having policies in place, the facility did not prevent recurrence of these issues, as evidenced by repeated citations over several years.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital, but the facility failed to document the transfer, notify the physician and family, or provide a bed hold notice as required by policy. Review confirmed these omissions in the resident's electronic health record.
A resident's MDS assessment did not reflect a serious mental illness diagnosis as determined by the state Level II PASRR, despite clinical records and PASRR documentation confirming the condition. The facility's policy required accurate documentation of all medical and psychosocial issues, and staff confirmed the expectation for accuracy.
A resident with multiple mental health diagnoses and prescribed psychotropic medications did not have an updated PASRR evaluation submitted after changes in their condition and care plan. The original PASRR indicated no mental health conditions or related medications, despite subsequent documentation and care plan updates reflecting significant mental health issues and medication use. Facility staff confirmed that no new PASRR was submitted, contrary to policy requirements.
A resident with multiple chronic conditions and incontinence did not have a comprehensive care plan addressing toileting hygiene or assistance. Staff and DON confirmed the absence of toileting interventions in the care plan, and repeated observations noted a strong urine odor in the resident's room, with inconsistent incontinence care documented.
A resident with multiple diagnoses, including dementia and mobility issues, experienced a fall resulting in a right clavicle fracture. Despite new orders for weight bearing as tolerated to the right upper extremity, the care plan was not updated to reflect the fracture or the new mobility status, contrary to facility policy and documentation in the health record.
Nursing staff did not document or implement a pharmacist-recommended gradual dose reduction for a psychotropic medication in a resident with multiple complex diagnoses. Despite agreement from the NP, there was no evidence that the order was processed or clarified, and the resident continued on the same dosage, contrary to facility policy requiring proper documentation and follow-through on medication changes.
Surveyors found that a resident's medications were pre-set and left in a medication cart, and that opened stock medications were not dated as required. A CMA confirmed the practice of setting aside medications for later administration, and the DON acknowledged that this did not follow facility policy, which requires medications to be prepared at the time of administration and opened medications to be dated.
Two residents did not receive adequate supervision or environmental safety as required by facility policy. One resident, with complex medical needs, was allowed to smoke unsupervised and without protective equipment, despite care plan requirements. Another resident with moderate cognitive impairment and mobility issues left the facility without staff knowledge or following the sign-out protocol, leading to a facility-wide search before he was located and returned.
A resident with multiple complex medical conditions, including ESRD and a central venous catheter, was admitted without proper assessment or care planning for the central line. Facility staff failed to obtain treatment orders, monitor the site, or perform dressing changes, despite documentation and resident reports indicating the line was present and the dressing was dirty. The facility did not follow its policy requiring physician notification and treatment orders for wound or line care.
A resident with a history of SUD and multiple behavioral health diagnoses exhibited erratic and escalating behaviors, including agitation and threats, which led to hospitalizations and positive drug screens. Facility staff reported not receiving training specific to SUD, and the resident's care plan lacked risk assessments, monitoring strategies, and interventions for substance use or overdose. The facility's behavioral health training and policies did not address SUD, resulting in inadequate support for the resident's behavioral health needs.
A resident with a history of diabetic foot ulcers did not receive diabetic shoes as ordered, leading to the development of a foot ulcer and subsequent amputations. The facility failed to follow up with the shoe vendor, despite the resident's request and worsening condition. Interviews revealed that the vendor requested additional paperwork, but the facility did not provide it, resulting in a lack of preventative foot care.
The facility failed to update care plans for several residents following changes in advance directives and smoking status. Discrepancies were found between IPOST and care plans, and smoking safety measures were not documented. Staff interviews revealed that established procedures for updating care plans were not consistently followed.
Failure to Assess and Follow Up on Significant Changes in Condition
Penalty
Summary
The facility failed to conduct comprehensive, ongoing nursing assessments and interventions for 7 of 7 residents reviewed for significant changes in condition. The cited residents included individuals with falls, hospital or ER returns, altered mental status, pneumonia treated with antibiotics, nausea and vomiting, rib fractures of unknown origin, and skin injury of unknown origin. Survey findings showed that nursing follow-up was incomplete or absent after these changes, including missing assessments, missing vital signs, missing neurological checks when indicated, and missing progress note documentation. For one resident, the record showed an unwitnessed fall out of bed with facial injury, swelling, and pain, followed by an ER visit and return with antibiotic orders for a UTI with hematuria. The facility documented only one full set of neurological checks after the fall, and the chart lacked nursing progress notes for a prolonged period despite staff interviews indicating a significant change in mental condition. The resident later returned to the hospital with altered mental status and hypothermia and was admitted to the ICU; the resident subsequently died at the hospital, with sepsis listed as the cause of death and other significant conditions including chronic osteomyelitis, diabetes, chronic subdural hematoma, atrial fibrillation, acute kidney injury, and hypertension. Other examples included a resident treated with an antibiotic for pneumonia over several days without comprehensive nursing assessment and intervention, a resident with nausea and vomiting who received antiemetic medication twice over a 6-hour period without documented assessments before cardiac arrest and CPR, and residents with rib fractures, a fall, pneumonia treatment, and a fall from a chair with a skin injury of unknown origin who also lacked adequate nursing assessment and follow-up. The facility was cited for failing to provide appropriate treatment and care according to orders, resident preferences, and goals because the nursing record did not show timely, comprehensive assessment and intervention in response to these significant changes in condition.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and to prevent new pressure injuries for multiple residents who were at risk. Resident #73 had severe cognitive impairment, was wheelchair dependent, totally dependent for transfers and toileting, frequently incontinent of urine, and received hospice services. The resident’s record showed a pressure reducing device for the chair was part of the skin treatment plan, but the resident developed a facility-acquired Stage 4 pressure sore to the lower right posterior thigh/back of the left thigh area. The wound was documented with eschar, slough, drainage, tenderness, and later odor, and the record noted the wound lined up with the wheelchair seat. The report also states the facility failed to utilize a pressure reducing wheelchair cushion until after the wound developed, failed to maintain pressure relief once the wound was present, and failed to provide major repositioning changes and incontinence care over a 7.5-hour period based on continuous observation. Resident #83 also had significant skin integrity problems, including a facility-acquired Stage 4 pressure sore to the left hip and a chronic pressure ulcer to the left heel. The resident’s skin assessments identified the need for protective prevalon boots to the bilateral lower extremities, but the report states the facility failed to provide the ordered protective prevalon boot to the left foot and failed to ensure all skin interventions were implemented. The report further states the facility failed to prevent friction and shear when providing incontinence care for this resident who had a Stage 4 pressure sore to the left hip. Resident #94 had a pressure sore to the left heel, and the facility failed to provide proper care for that wound and failed to implement measures to prevent a pressure sore to the right heel. The report identifies these failures as part of a broader pattern involving 4 of 4 residents reviewed for pressure sore prevention and interventions, and states the deficiencies rose to the level of Immediate Jeopardy. The report also includes survey findings from a 100% skin sweep showing multiple residents with pressure injuries, moisture-associated skin damage, and other skin concerns, along with documentation that the facility’s staffing assessment reviewed hall assignments, resident acuity, incontinence care, repositioning, transfers, wound care, and equipment needs.
Delayed Pain Assessment and Medication Implementation
Penalty
Summary
The facility failed to timely and effectively manage pain for a resident with multiple fractures, wounds, oxygen use, therapy needs, and hospice admission. The resident’s record showed pain that interfered with sleep and therapy, and the hospice admission note documented crying out in pain, a PAINAD score of 8/10, anxiety, and increased agitation with movement or transfers. The resident also had pressure injuries, skin tears, bruising, a surgical wound, and a leg brace, with staff and therapy notes describing restlessness, agitation, pulling at the brace and catheter, and body language consistent with discomfort. On the day of the event, family members reported that the resident was found tipped forward in a recliner with the footrest on the floor, and they described a new arm wound, bruising, fear, labored breathing, and severe pain. The wife stated she notified staff and did not receive a nurse response for hours, while the grandson reported the resident repeatedly asked to go home and not be left alone. The nursing note documented the recliner being repositioned and the resident being settled, but the record lacked follow-up documentation overnight after the hospice nurse ordered morphine for difficult breathing and severe pain. The record also showed gaps in pain assessment and medication implementation. A pain assessment was not completed on one date, and later pain documentation showed a score of 6/10 earlier in the day but then 0 overnight without supporting reassessment details. Staff interviews reflected uncertainty about whether the resident was assessed after the recliner incident, whether the new abrasion was evaluated, and whether pain medication was given. A follow-up interview indicated the morphine order was delayed because the e-script was not received correctly by the pharmacy, the medication was not available in the emergency supply, and a stat order had to be obtained. The grievance records also showed other residents complained that pain medications were not given timely or were not available, with follow-up documentation lacking resident verification of resolution and lacking confirmation of whether the grievances were substantiated.
Physical Abuse During Resident Handling and Broader Care Failures
Penalty
Summary
The facility failed to prevent physical abuse for Resident #81 during assistance with bed mobility and transfers. Resident #81 had a BIMS score of 15, indicating intact cognition, and required extensive assistance, including a hoyer lift for transfers. The resident reported that staff held his arms too hard when rolling him, and the incident report documented bruising to the left wrist/hand and right elbow after care was provided. The bruises were described as deep purple, and photographs showed finger-mark-like lines at the wrist area and a large bruised area at the elbow region. The record also showed that Resident #81 had previously reported that nursing staff did not listen to him and that call light response times were long. The incident documentation stated the resident was alert and oriented and said he was not harmed intentionally, but he specifically linked the bruising to the way staff handled him during rolling. The facility’s skin documentation on the day after the incident recorded no bruises despite the documented bruising and photographic evidence from the prior day. The report also identified additional abuse- and neglect-related concerns involving other residents, including rude or intimidating staff interactions, incomplete investigations of resident-to-resident incidents, and repeated failures to provide timely assistance with ADLs, incontinence care, repositioning, grooming, oral care, and call light response. One resident was documented as having been left without needed care for an extended period, and another resident was found with rib fractures of unknown cause after an ER visit, with the investigation not identifying the cause of injury. These findings were documented through grievance records, clinical record review, observations, and interviews.
Unsafe Smoking Supervision and Missing Smoking Assessments
Penalty
Summary
The facility failed to ensure residents received safe smoking assessments at the required intervals and failed to provide adequate supervision and protective interventions during smoking for multiple residents. Several residents were identified as smokers with varying levels of cognitive impairment, physical limitations, and supervision needs, yet the record showed missing, outdated, or inconsistent smoking assessments and care plan interventions. Residents documented as needing supervision or protective equipment were observed smoking without a smoking apron, and staff were observed unable to maintain supervision of all residents in the designated smoking area. Resident #46 had a history of stroke, hemiplegia, diabetes, depression, and required substantial assistance with transfers and mobility. The care plan stated the resident was to be supervised while smoking because of prior burn marks on clothing and shoes, and the most recent smoking assessment documented that the resident could not extinguish smoking materials appropriately or dispose of ashes safely. Resident #51 had cancer, stroke history, hemiplegia, heart failure, COPD, and required supervision for transfers; the smoking assessment documented that the resident could not safely light a cigarette and needed a smoking apron, and IDTC notes stated the resident was legally blind. Resident #56 had stroke-related speech deficits and required substantial assistance with ambulation; the smoking assessment required supervised smoking. Resident #71 was documented as a current smoker, but the care plan did not identify current smoking status and the EHR lacked a smoking assessment until one was later requested. Resident #78 had stroke, diabetes, hemiplegia, contractures, and dependent transfers; the care plan required supervision and a smoking apron, but the smoking assessment documentation identified the resident as needing supervision for safety. Resident #80 had cancer, heart failure, peripheral vascular disease, a below-the-knee amputation, kidney failure, diabetes, non-Alzheimer’s dementia, and used a prosthesis and wheelchair. The resident sustained a thermal burn to the right heel after stating that the cigarette cherry fell into the shoe. The smoking assessment documented that the resident had a burn wound to the right foot from a cigarette cherry falling into the shoe and required supervision during smoking sessions with a smoking apron. During observation, staff assisted one resident to the smoking area and lit the cigarette, but did not provide a smoking apron, and multiple residents who required supervision were left outside smoking without staff present. The observation also showed staff inside the building while residents continued smoking outside unsupervised, and staff were unable to respond when one resident’s wheelchair became caught in the door jam.
Insufficient Staffing Caused Delays in Call Light Response and Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift, as shown by repeated reports of delayed call light response, delayed incontinence care, and delayed assistance with activities of daily living. The facility assessment identified many residents needing transfer assistance and toileting assistance, including residents requiring mechanical lifts and residents who were fully incontinent, but the assessment did not reflect the current resident needs for May 2026 or explain how staffing patterns were reviewed to address the increased care needs. Resident council minutes from two meetings documented resident concerns that call light wait times were still long and that staff should check more often on residents in common areas during evenings and nights. Monthly grievance forms documented repeated complaints from residents and family members that call lights were not answered timely, residents were left wet or soiled for extended periods, and assistance with toileting, showers, meals, and other ADLs was delayed or not provided. One resident reported not being checked and changed on the overnight shift, another reported waiting 45 minutes for help, another reported sitting in feces for 14 hours, and another reported call lights taking an hour or more to be answered. A family member reported a resident turned on the call light at 6:10 PM and no one came to help until 6:45 PM. Several grievances also described staff turning off call lights and leaving without helping, residents waiting 30 minutes to 2 hours for toileting assistance, and residents not receiving showers, snacks, or meal trays in a timely manner. Resident interviews and observations further documented the staffing-related care delays. One resident with diagnoses including heart attack, stroke, CHF, and pulmonary disease, and who depended on staff for toileting and required total assistance from two staff for bed-to-chair transfers, reported waiting over 2 hours to have a bowel movement and described staff turning off the call light and leaving without assisting. Another resident reported call lights taking forever, frequently waiting over a half hour on all shifts, and being left in a wheelchair for over an hour after being brought back to the room. A resident on the 300 hall was observed dressed in a hospital gown and, during continuous observation from 4:20 AM to 12:00 PM, staff failed to provide grooming, dressing, oral care, major position changes, or incontinence care. Staff interviews also described difficulty getting residents up in the morning because of heavy care needs, the need for a second aide to assist, and delays caused by having only one aide available on the hall.
Facility Assessment Not Updated for Leadership and Resident Care Needs
Penalty
Summary
The facility failed to revise its facility-wide assessment to reflect current resident care needs and leadership changes. The assessment dated [DATE] stated it was last reviewed in May 2026 with no changes needed, but it still listed leaders who were no longer employed by the facility. Recent leadership changes included a new DON in September 2025, a new MDS Coordinator in October 2025, and a new Administrator in January 2026. The assessment also did not accurately reflect the number of residents needing assistance with transfers and incontinence care. The assessment identified 48 residents needing transfer assistance and 53 needing toileting assistance, while a resident roster dated 5/18/26 for a census of 84 documented 64 residents needing transfer assistance, including 9 who required an EZ sit-to-stand mechanical lift and 20 who required a Hoyer full body mechanical lift. The roster also documented 79 residents with incontinence, including 6 with mixed incontinence and 73 who were fully incontinent. In addition, the assessment did not reflect the current number of residents on Enhanced Barrier Precautions. The assessment identified 11 residents on EBP and 1 acute infection, while observation on 5/11/26 found 19 room doors with EBP signs outside the rooms. The assessment also stated staffing patterns were regularly reviewed and adjusted to align with changes in resident acuity and care plans, and that staffing for other departments was adequate, but it did not reflect the current resident needs or how staffing patterns were reviewed to address the increase in care needs. The Administrator confirmed she signed the May 2026 review indicating no changes were needed and did not provide further response during the survey.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to implement infection prevention and control practices and Enhanced Barrier Precautions (EBP) for multiple residents whose care plans directed EBP use. Resident #19 had a chronic left foot ulcer with MDRO history and a care plan requiring EBP, weekly wound assessments, and physician treatment orders. During observation, the resident had a dressing on the left leg, but there was no PPE at the door and no sign indicating EBP. The resident stated staff only wore gloves during dressing changes and did not use handwashing or a gown. Resident #6 had an MDRO history and a urinary catheter, and the care plan directed EBP related to urinary output, incontinence, and ESBL history; however, observation showed no PPE at the door and no EBP sign, and staff interviewed were unaware the resident required EBP. For Resident #83, who had severe cognitive impairment, total dependence for toileting hygiene, incontinence of bowel and bladder, and multiple pressure injuries including a Stage 4 ulcer, surveyors observed repeated failures during incontinence care and wound care. Staff entered the room without PPE despite an EBP sign being present, handled soiled briefs and wipes with contaminated gloves, changed gloves without washing hands, and did not cleanse all areas contaminated by urine or feces. Soiled trash bags and linens were placed on the floor in the hallway and in an empty room used for garbage and soiled linen bags. During shower transfer and wound treatment, staff again failed to perform hand hygiene after glove removal and handled equipment and resident care items without cleaning between tasks. Resident #52, who was totally dependent for toileting hygiene and always incontinent of bowel and bladder, was observed during personal care with a strong ammonia odor in the room. Staff changed gloves without washing hands, placed clean supplies on the bed without a barrier, and did not cleanse all areas contaminated by the soiled brief before replacing it. Resident #85, who had severe cognitive impairment, an indwelling catheter, and bowel incontinence, was observed receiving perineal care in which staff wiped only limited areas, placed a soiled brief on the bed with clean wipes, and continued care with contaminated gloves before washing hands. After removing gloves, a CNA touched the resident’s soda bottle and provided a drink without hand hygiene. Resident #73, who had moderate cognitive impairment, bowel and bladder incontinence, a Stage 4 pressure injury, MASD, and hospice services, was observed with a strong ammonia smell in the room and a heavily soiled brief; staff failed to change soiled gloves or sanitize hands before placing a new brief and did not cleanse all skin areas contacted by the brief. The report also states the facility lacked tracking records for the entire facility and antibiotic stewardship program from January 2026 to June 2026, and that soiled laundry and clean laundry were not handled with appropriate infection control measures.
Failure to Provide Timely ADL and Incontinence Care
Penalty
Summary
The facility failed to provide timely and complete assistance with activities of daily living for residents who needed help with toileting, incontinence care, grooming, oral care, transfers, and showers. Grievance documents and interviews described repeated complaints that residents were left wet or soiled for extended periods, call lights were not answered promptly, showers were missed or delayed, and residents did not receive needed help with toileting or personal care. Several grievances involved residents reporting that staff did not check and change them overnight, did not provide requested showers, did not answer call lights, or left them waiting for assistance with toileting and hygiene needs. Resident #81 had intact cognition and care plans directing staff to assist with oral hygiene, bathing, dressing, toileting checks every 2 to 3 hours, and transfers with a Hoyer lift and 2-person assistance. The resident reported call lights took a long time to answer, that staff often said they were short-staffed, that he had waited up to 2 hours for help, and that he frequently waited over a half-hour on all shifts. He also stated he was left in his wheelchair for over an hour after being brought back to his room and, during an interview, was wet with urine and had a bowel movement while still waiting for incontinence care. Resident #73 had moderate cognitive impairment and required extensive assistance for transfers, toileting, personal hygiene, dressing, and oral care, with constant bowel and bladder incontinence. During a continuous observation, staff did not provide major position changes, incontinence care, grooming, or oral care for several hours, and the resident remained in bed in a semi-Fowler's position while staff cared for other residents. When care was finally provided, staff assisted with incontinence care, dressing, and transfer but skipped oral care, and the room had a strong ammonia odor with the brief heavily soiled with urine and feces. Resident #83, who had severe cognitive impairment, constant bowel and bladder incontinence, and pressure ulcers including a Stage 3 left hip wound and an unhealed Stage 4 pressure ulcer, was observed with a heavily soiled brief and fecal contamination while staff performed incomplete cleansing. Similar observations were documented for Resident #52, Resident #85, and Resident #86, each of whom had significant cognitive and physical impairments and required staff assistance for toileting hygiene and incontinence care, yet were observed wet, soiled, or receiving incomplete personal care.
Failure to Provide Restorative Nursing Programs for Residents With Mobility Needs
Penalty
Summary
The facility failed to provide a restorative program for residents with mobility concerns for 4 of 4 residents reviewed. The deficiency was identified through observations, interviews, and record review, and the facility reported a census of 81. Records showed that each of the four residents had mobility-related needs documented in their MDS assessments and care plans, yet their care plans lacked restorative nursing programs, and the MDS assessments documented 0 of the past 7 days of restorative nursing program participation for each resident. Resident #3 had diagnoses including heart failure, hypertension, diabetes mellitus, anxiety, and depression, and the MDS documented an impairment of the lower extremity. Her care plan lacked a restorative nursing program. She stated that she did not think a restorative program existed at the facility, that she did not work with anyone, and that the facility only offered Tuesday group exercises. She also stated that she wanted to get up and walk and talk to therapy about her walker. Staff interviews reflected that therapy did not have a restorative program in place, that therapy used a therapy-to-nursing CNA handoff maintenance plan, and that the facility relied on communication books, huddles, and Kardex information rather than a formal restorative nursing program. Resident #71’s MDS documented intact cognition, diagnoses including UTI, multiple right rib fractures, COPD, cirrhosis, anxiety, and depression, and mobility needs requiring partial to moderate assistance or supervision with wheelchair use. The care plan included assistance with ADLs, ambulation with a FWW and wheelchair follow, and encouragement to report decline, but it lacked a restorative nursing program. Resident #83’s MDS documented severely impaired cognition, Down Syndrome, aftercare following hip replacement, wound infection, adult failure to thrive, pressure ulcers, and substantial to maximal assistance for ambulation, with walker and wheelchair use. His care plan directed staff to encourage him to do as much as possible and use a wheelchair, but it also lacked a restorative nursing program. A confidential interview stated that staff had to respect refusals, that he needed more encouragement, and that he had declined from walking and standing to needing more assistance. Resident #85’s MDS documented severely impaired cognition, neurogenic bladder with catheter, aphasia, stroke, hemiparesis, dysphagia, pressure ulcer, and right-hand contracture, with dependence for ambulation using a wheelchair. Her care plan directed PT, OT, and ST, ROM with morning and evening care, and repositioning or ambulation every 2 hours as tolerated, but it lacked a restorative nursing program. CNA interviews stated that staffing shortages and lack of training affected completion of ROM and exercises, and that CNAs had not received facility training on each resident’s restorative therapies beyond basic CNA school instruction. The DON stated that CNAs were educated by therapy during onboarding and that residents needing ROM or adaptive equipment were noted on the Kardex.
Failure to Demonstrate Nursing Competency in Infection Control, Incontinence Care, and Resident Assessment
Penalty
Summary
Nursing staff failed to demonstrate the competencies and skills needed to provide care that met residents’ needs, including infection prevention practices, incontinence care, and use of Enhanced Barrier Precautions (EBP). During observed care for multiple residents, CNAs were seen entering rooms without appropriate PPE, failing to perform hand hygiene between contaminated tasks, and providing incomplete cleansing during incontinence care. Staff handled soiled briefs, wipes, linens, and equipment with contaminated gloves, changed gloves without washing hands, and in several instances did not cleanse all areas exposed to urine or feces before placing clean briefs or continuing care. For one resident with severe cognitive impairment, Down syndrome, pressure ulcers, a wound infection, and dependence for transfers and personal care, staff observed a heavily soiled brief and fecal contamination during incontinence care. Staff failed to cleanse all contaminated areas, used contaminated gloves repeatedly, and removed the brief with audible friction and shear against the resident’s skin. Staff also failed to consistently use PPE despite an EBP sign on the door, and one CNA stated she had not received specific facility training on EBP since hire. Similar failures were observed with other residents, including incomplete cleansing, handling of soiled items without proper hand hygiene, and continued contact with resident care items after glove removal. Licensed nursing staff also failed to demonstrate the knowledge and competencies needed to assess, monitor, and communicate residents’ conditions. One resident developed a rash that progressed to bilateral leg involvement, hypotension, lethargy, decreased intake, and eventual transfer to the ER, where the facility reported the resident had become hypotensive and was admitted for IV antibiotics and later diagnosed with sepsis related to cellulitis. Interviews reflected that staff could not clearly describe the resident’s baseline or current condition, and one nurse stated she did not know much about the resident. Another resident’s G-tube feeding orders and dietitian recommendations were inconsistently communicated and transcribed, with staff uncertainty about whether the feeding was on hold, resumed, or discontinued, and the record did not show timely clarification of the changing orders.
Failure to Respect Resident Dignity During Toileting Assistance
Penalty
Summary
The facility failed to respect a resident’s dignity throughout care and failed to speak to the resident with dignity and respect. Resident #25 had diagnoses including heart attack, stroke, CHF, and pulmonary disease, and the MDS showed a BIMS score of 14, indicating intact cognition. The MDS also showed the resident was dependent on staff for toileting and required total assistance of two staff for bed-to-chair transfers. On 4/13/26, Resident #25 requested assistance to use the restroom during medication pass, and the LPN left to find additional staff. Later that morning, the resident’s call light was on and a CNA was observed exiting the room. The resident reported that the CNA came in, turned off the call light, shrugged her shoulders, and walked out without assisting him. The resident stated he waited over 2 hours to have a bowel movement and felt abandoned due to short staffing. The resident’s son also expressed concern about the quality of care, and staff documentation recorded the resident’s complaint that he had requested help to the toilet and was left waiting after staff turned off his call light and left the room.
Resident bathing preference not honored
Penalty
Summary
The facility failed to honor Resident #81’s choice of bathing time and did not include that preference in the care plan. The resident’s MDS assessments documented that choosing between bathing options was very important to him, and the quarterly assessment showed intact cognition with a BIMS score of 15. The resident also had diagnoses including debility and cardiorespiratory conditions, and his functional status indicated he was dependent on a helper for mobility and showering. The care plan addressed adjustment to the facility, self-led activities, and assistance with ADLs related to weakness and decreased mobility, but it did not identify any preference for bathing time or the level of assistance to be provided for showers. During interview, Resident #81 stated that Tuesdays were his shower days and that he preferred to shower at 11:00 AM. On observation, staff were preparing him for a shower at about 7:03 AM, and CNA Staff EE spoke to him in an argumentative manner and interrupted him when he explained his preference. The resident stated staff told him it was time to wake up and take his shower, and later said he would not be told what to do and when to do it. He also stated he believed Staff EE provided the shower at 7:00 AM because she told him the State expected the shower to be done at that time.
Failure to Timely Report Abuse and Injury Allegations
Penalty
Summary
The facility failed to report allegations of abuse and injuries of unknown origin to DIAL in a timely manner for two residents. One resident, who was cognitively intact with diagnoses including UTI, COPD, cirrhosis of the liver, anxiety, depression, and prior right rib fractures, developed worsening right-sided pain and was sent to the ER. Imaging showed an age-indeterminate but presumably acute nondisplaced right posterior 11th rib fracture that was new compared with prior imaging. The facility completed an internal investigation and a physician signed a non-major injury form, but the facility later acknowledged that the rib fracture of unknown origin had not been reported to the Regional Director of Operations or DIAL. The second resident, who was cognitively intact and required extensive assistance with ADLs and Hoyer lift transfers, had bruising to the left wrist and right elbow/forearm after care and rolling. The resident stated the staff grabbed him too hard when moving him and that they held on too hard. The incident report documented deep purple bruises, and photographs showed finger-mark-like lines at the wrist and a large bruise at the elbow/forearm. The resident later repeated that staff were too rough when they grabbed his arms to move him, and he described staff grabbing his arms harshly and leaving bruises. The facility’s documentation did not show that this event was treated as an allegation of abuse or that an abuse investigation file was submitted to the State Survey Agency. The Administrator stated the bruising was not treated as abuse because it was not considered unknown origin since the resident knew the bruise was there, and the only documentation was a grievance form noting staff education. As of the survey date, no abuse investigation file had been received related to the bruises on the resident’s wrist and elbow, and the facility failed to report the allegation of abuse to the State Survey Agency.
Incomplete Abuse and Injury Investigations
Penalty
Summary
The facility failed to conduct thorough investigations of allegations of abuse and injuries of unknown origin for two residents. For one resident with intact cognition, the record showed bruising to the left wrist and right elbow after care and rolling, with the resident stating staff grabbed him too hard when turning him. The incident report documented deep purple bruises, the resident’s statement that staff held on too hard, and photographs showing patterned bruising consistent with finger marks. However, the grievance documentation did not show that an abuse investigation was initiated, and the facility administrator later stated the bruising was not treated as an allegation of abuse because the resident knew the bruise was there. The same resident later reported that staff grabbed his arms harshly when helping move him and that some staff were too rough when turning him. During survey observation in the shower room, a CNA spoke to the resident in a manner that the surveyor perceived as intimidating, and the resident and CNA were overheard in a back-and-forth exchange. The surveyor reported an allegation of potential intimidation and verbal abuse, but the facility’s investigation file was limited. It included a few staff and resident statements, but it did not include a written statement from the surveyor who made the initial report, and the final investigation summary omitted statements that described the CNA speaking harshly to the resident. The administrator also stated the investigation was good enough based on the resident’s denial of feeling threatened, despite the surveyor’s report and staff comments that the CNA was rude and disrespectful to residents. For the second resident, the record showed an acute episode of right-sided abdominal and rib pain that led to an emergency room visit and a diagnosis of a right 11th rib fracture. The resident was cognitively intact and denied falling or recent injury. The facility investigation form documented the fracture and pain, but the report excerpt provided did not show a completed explanation for the injury’s cause or a full abuse/injury-of-unknown-origin investigation. The facility policy defined abuse and listed physical marks such as bruises and physical injury of unknown source as possible indicators, but the policy review noted it lacked a definition for injuries of unknown origin as defined in the State Operations Manual.
G-tube Feeding Order Not Followed and Order Communication Was Unclear
Penalty
Summary
The facility failed to ensure staff followed a G-tube feeding order for a resident with severe cognitive impairment, stroke-related deficits, aphasia, hemiplegia, dysphagia, and dependence on tube feeding. The resident’s MDS documented a BIMS score of 4 and extensive physical dependence, but it did not document the G-tube for feeding and nutrition. The care plan identified the resident as at risk for altered nutrition and hydration status related to cognitive status, post-stroke condition, feeding tube, foley catheter, and being bed or chair bound, and another care plan focus stated the resident required tube feeding because of dysphagia secondary to stroke. The resident’s nutrition record showed that the RD recommended holding G-tube feedings for six nights and asked the provider to approve the hold. The ARNP later documented that the resident remained G-tube dependent and was stable on night feeds via the G-tube, with continued discussion about reducing dependence pending swallow study results. The MAR/TAR reflected a feeding order for Osmolite 1.2 from 9:00 PM to 3:00 AM, with a hold beginning on 5/12/26 and a discontinuation date of 5/15/26. Nursing documentation showed the feeding was held on 5/12/26, 5/13/26, and 5/14/26, and then the order was extended through 5/21/26. The MAR/TAR for the extended order showed the feeding was administered on 5/15/26 and 5/16/26, held on 5/17/26 through 5/19/26, and administered again on 5/20/26 and 5/21/26. The resident also had an order for 60 mL water flushes every hour via the G-tube during the feeding period, and those flushes were documented as completed as ordered. Staff U stated that he connected and administered the feeding on 5/15/26 as shown on the MAR, but on 5/16/26 he did not administer the feeding as indicated because he learned during shift report that the feeding required a hold and he could not find an order in the EHR stating that the feeding remained on hold or was discontinued. On 5/21/26, observation of the resident’s room found a bottle of Osmolite with 400 mL remaining and a feeding bag with 500 mL of water hanging on a pole with tubing inserted through the feeding pump, with no date of use on either item. A feeding syringe and graduate were also present on the bedside table labeled 5/20 PM. Later review of the EHR showed that the 5/22/26 RD recommendation to discontinue the G-tube feedings and water flushes had not been documented as communicated to, reviewed by, approved by, or declined by the physician, and the facility identified concerns with the communication, transcription, and follow-up process related to the dietitian’s recommendations and the G-tube feeding order.
Medication Administration and Order Reconciliation Failures
Penalty
Summary
The facility failed to administer insulin as ordered for one resident with intact cognition and diagnoses including diabetes mellitus, hypertension, anxiety, and depression. The physician orders required Insulin Lispro after meals based on meal consumption, with additional correction doses based on blood glucose levels. Review of the May MAR showed the scheduled insulin was not administered on two dates because staff documented it as a duplicate order. An LPN stated she must have misread the order and acknowledged she did not give the insulin on those days, and the DON verified there were two different insulin sliding scale orders and expected the nurse to verify and administer the insulin according to the order. The facility also failed to discontinue an anticoagulant for another resident with a history of DVT and PE. The resident’s hospitalization summary documented admission for acute blood loss anemia secondary to vaginal bleeding, that Xarelto was held on admission, and that the bleeding resolved. The summary further stated there was no specific reason for chronic anticoagulation given the resident’s vaginal bleeding and multiple prior GI bleeding episodes, and it recorded that the anticoagulation was discontinued. Despite this, the February, March, and April MARs continued to show Xarelto 20 mg daily with supper as an active medication. The resident repeatedly refused the medication because she believed it had been discontinued during the hospitalization, and staff documented that the medication remained active on the MAR. A nurse later contacted the physician, who reviewed the discharge summary and confirmed the discontinuation, and an NP note also documented that the anticoagulation had been discontinued during the last hospitalization but remained active on the MAR. The care plan was not revised to reflect the discontinuation, and the MDS still identified anticoagulant use within the recent assessment period.
Failure to Post Current Daily Staffing Information
Penalty
Summary
The facility failed to post the daily staffing report in a public location for residents and visitors to see on a daily basis. With a census of 81 residents, observation on 5/23/26 at 7:07 PM found the staffing report posted by the east entrance before the dining/activity room, but the print was very small and hard to read from greater than 12 inches away and from an approximate height of 5 feet. The posting was kept in a page protector sleeve with several forms inside, and the top page was dated 5/20/26 while the other forms behind it were dated prior to 5/14/26. No posting since 5/20/26 was found anywhere else in the facility. Staff interviews showed the current staffing schedule was kept in the staff breakroom, not in a public location. An LPN stated the schedule was in the breakroom, and an RN stated he knew nothing about the daily staff posting. When the Administrator was asked for staffing assignments for Saturday through Monday because the daily posting was not current, she provided hall assignment sheets that did not include the total number and actual hours worked by nursing staff, and no public posting was done after the request. On 6/1/26, the daily staff posting near the east entrance still showed 5/28/26 as the most recent posting, with older sheets behind it dating back to 1/13/26. The Administrator stated she did not know why the posting was not current and said the scheduler was responsible for posting it, but could not explain who would post it on weekends.
Unlocked Medication Carts Left Unattended
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to properly secure medications from unauthorized access. Based on observations, staff interviews, and policy review, 2 of 2 medication carts observed were left unlocked in resident hallways in front of the nurse's documentation room. On 01/06/26 at 4:56 AM, an unlocked medication cart containing duloxetine and Baclofen was observed in the hall, and Staff I, LVN, was sitting in the documentation room while the cart drawer remained open for one full minute before she approached it. She stated the carts should not be left unlocked but added she was about to access the cart. On 1/07/26 at 3:05 am, an unlocked medication cart and supply cart were found in the resident hallway with no staff members or residents visible in the unit hallway. The cart contained duloxetine, trazadone, Eliquis, and Baclofen. After three minutes, Staff J, RN, approached the cart and stated the medication and supply carts should be locked when left unattended. The facility's Medication Storage policy revised 01/2025 stated that all drugs and biologicals must be stored in locked compartments, only authorized personnel may have access to the keys, and medications during a medication pass must be under direct observation or locked in the medication storage area/cart. On 1/08/26 at 2:26 PM, the DON stated staff should lock the medication carts when stepping away from the computer.
Palatability of Served Sandwiches
Penalty
Summary
The facility failed to prepare and serve food that was palatable for one of four hallways observed during the lunch meal service. On 1/7/26, dietary staff removed a large pan of ham and cheese sandwiches from the oven and reported the sandwich temperature at 130 degrees Fahrenheit. Staff then placed another pan of buns with ham and cheese into the oven, wheeled the warming cart to the dining room, and served residents in the dining room while the second pan remained in the oven for 40-45 minutes. After the dining room residents were served, staff removed the second pan from the oven and reported the sandwich temperature at 147 degrees Fahrenheit. Room trays for the 100 hall were plated later, and a test tray obtained from the 100 hall cart showed the ham and cheese sandwich was hard to cut, with a very hard and dry bun around the edges and only the middle section edible. Resident interviews from the 100 hall indicated three of four interviewable residents said the bun was hard and difficult to eat, one resident said the food was not good, and another said the sandwich was gross and she could only eat half of it. The Dietary Supervisor stated the bread came frozen from the vendor and that the buns looked kind of hard when removed from the oven, and she thought the length of time in the oven may have caused the buns to dry out. The facility policy stated food shall be prepared by methods that conserve nutritive value, flavor and appearance, and food palatable and attractive.
Unattended EHR Laptop Exposed Resident Information
Penalty
Summary
The facility failed to properly protect resident information from unauthorized access when an EHR laptop was left accessible on a resident hall with 11 residents' information visible. On 1/06/26 at 5:05 AM, surveyors observed the laptop displaying EHR information for residents 301, 304, 305, 306 A, 307, and 308 while it was unattended. At 5:09 AM, Staff H, an RN, stated that laptops are not to be left open when staff are not present and said he did not know it was open. On 1/08/26 at 2:26 PM, the DON stated the laptop screen should be locked when staff walk away. A facility policy titled HIPAA Security Measures, revised 02/2025, stated that physical safeguards will be implemented to limit physical access to electronic information systems while ensuring properly authorized access is allowed.
Failure to Maintain Resident Dignity, Timely Call Light Response, and Appropriate Pain Management
Penalty
Summary
Facility staff failed to maintain resident dignity and timely response to needs in multiple situations. One cognitively intact resident with osteoarthritis, chronic pain, and a history of a fall with fracture required assistance of one staff for toileting and transfers and was non‑weight bearing to the left lower leg while receiving therapy for a leg fracture. This resident reported that a CNA assisted her onto the toilet and left the room; after activating the call light within about five minutes, no staff responded for approximately 45 minutes, despite her roommate observing several staff walking past the room without answering the call light. The resident stated that the CNA who eventually responded was not assigned to her hall and that being left on the toilet for that length of time made her feel like no one cared about her. The same resident also reported that when she requested PRN pain medication for left leg pain rated at 7, staff told her she could not receive PRNs at that time because they could not locate the assigned LPN. When the LPN did respond, the resident stated the nurse was mean and intimidating, insisted she would receive Tylenol instead of the PRN narcotic ordered for higher levels of pain, and that this behavior caused the resident to avoid requesting narcotics when that nurse was on duty. The resident reported sitting and crying for two hours due to pain and experiencing breakthrough pain related to therapy, and stated she had informed the DON that she endured a lot of pain because the LPN did not administer the requested PRN medication. Additional dignity concerns were identified with other residents. One resident reported that staff frequently entered his room without knocking, and this was observed when a staff member entered during an interview to check his ice without knocking. Another resident reported that staff had been entering his room without knocking for a long time and that he was fed up; this was observed when three staff entered his room without knocking and interrupted an interview. During a lunch observation, a dependent resident with CVA, malnutrition, aphasia, dementia, severely impaired cognition, and total dependence on staff for eating was fed by a CNA who sat with her elbow on the table, head resting on her hand, did not look at or interact with the resident, mechanically placed food and a straw into the resident’s mouth, and rubbed her eye before resuming feeding without apparent hand hygiene. These actions and inactions occurred despite facility policies on promoting/maintaining resident dignity and call light response, and staff and DON statements that expectations included timely call light response, knocking and announcing before entering, and providing appropriate pain control and dignified, engaged feeding assistance.
Failure to Include Fall-Prevention and Antianxiety Interventions in Resident Care Plans
Penalty
Summary
Surveyors identified that the facility did not develop and implement complete, individualized care plans for two residents following changes in condition and treatment. For one resident with a history of stroke, unsteadiness on feet, and muscle weakness, records showed the resident fell from bed while sleeping and was hospitalized. Progress notes documented that new fall prevention interventions would be determined upon the resident’s return and that the care plan was reviewed and updated. The revised care plan referenced the fall and directed staff to assist with mobility and maintain a clutter-free environment, but it did not include the specific intervention that staff had instructed the resident to follow: keeping the bed in the lowest position when asleep. During interviews, the resident confirmed staff had given this instruction, and an LPN and CNA both stated that such a bed-positioning intervention should appear in the care plan, but it was not present. For another resident with severely impaired cognition, non-Alzheimer’s dementia with behavioral disturbances, anxiety, and depression, the MDS and electronic health record documented an order for antianxiety medication and described the behaviors the resident exhibited when anxious. A progress note also described the resident’s anxiety behaviors and indicated they had not been recently observed. However, the resident’s care plan, although it listed an anxiety disorder, did not include the ordered antianxiety medication, did not specify the resident’s anxiety behaviors for staff to monitor, and did not outline any non-pharmacological interventions for staff to attempt. In interviews, an LPN and CNA indicated that the antianxiety medication, target behaviors, and related interventions should be included in the care plan, and the DON stated that care plans should be updated to accurately reflect care based on physician orders, consistent with the facility’s comprehensive care plan policy.
Failure to Protect Resident During Mechanical Lift Transfer and to Supervise At-Risk Smoker
Penalty
Summary
Surveyors identified that staff failed to protect a resident’s heels during a mechanical lift transfer. One resident with moderately impaired cognition, bilateral leg nerve damage causing muscle weakness, a history of stroke, and a documented moderate risk for pressure ulcer development required extensive assistance with ADLs and mobility. His care plan directed staff to follow facility protocols for prevention of skin breakdown. During observation of a bed-to-wheelchair transfer using a mechanical lift, an OT and a CNA repositioned the resident in the sling while his heels dragged across the mattress. After transfer, the OT exposed the resident’s heels and noted redness on the right heel. Multiple CNAs later stated that residents’ feet and bodies should not contact the mattress while being actively moved with a mechanical lift, and the DON stated staff should have lowered the bed or elevated the heels to prevent shearing or rubbing. The facility’s Safe Resident Handling/Transfers policy required safe handling and transfers to prevent or minimize injury and provide a safe, comfortable experience. Surveyors also found that staff failed to provide required supervision for an at-risk smoker who accessed the courtyard alone. Another resident with intact cognition but significant physical impairments, including hemiplegia, stroke, acute respiratory failure, hypertension, and diabetes, required extensive assistance with mobility and ADLs. A progress note and a Safe Smoking Assessment documented that he was not an independent smoker, lacked spatial and self-awareness, and required supervision for smoking. His care plan directed staff to supervise smoking, ensure cigarettes were fully extinguished, and assist him to and from the designated smoking area as needed. On one early morning, the resident wheeled himself through an exit door into the enclosed smoking courtyard by canceling the door alarm and activating the automatic door opener, with no staff present and no audible alarm heard. On another early morning, he opened the courtyard door and triggered the alarm, to which the DON immediately responded and reminded him he needed staff present to smoke. The facility’s Resident Smoking policy required that supervision be provided as indicated on each resident’s care plan.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves facility staff not consistently answering resident call lights within a reasonable amount of time, particularly during evening and night shifts. Multiple residents with intact cognition, as indicated by Brief Interview for Mental Status (BIMS) scores of 15, reported extended waits after activating their call lights for assistance with toileting and personal care. One resident stated that after being assisted to the toilet by a CNA, she activated her call light within five minutes but did not receive help back to bed for approximately 45 minutes. Another resident reported turning on the call light for toileting assistance and waiting about 30–45 minutes without a response, ultimately going to bed without being properly cleaned. A third resident reported experiencing prolonged call light response times for a long period during evenings and overnights, including an incident where he choked on mucous and waited about 15 minutes for staff to respond, during which he feared he was choking to the point of death before clearing it himself. Resident Council minutes from a recent month documented concerns that staff were turning off call lights, wearing earbuds during care, and that there were long wait times for call lights to be answered. The facility census was reported as 81 residents. The DON and CNAs interviewed stated that staff were expected to respond to call lights within an appropriate time and as quickly as possible, and the facility’s call light policy directed all staff who see or hear an activated call light to respond and notify appropriate personnel of the resident’s need.
Significant Medication Error Leading to ICU Admission After Wrong-Resident Administration
Penalty
Summary
A resident with intact cognition and multiple diagnoses including chronic kidney disease, peripheral vascular disease, hypertension, and diabetes was involved in a significant medication error shortly after admission. The resident reported that she was given medications that belonged to her roommate and stated she told the staff member the medications were not hers, but the staff member insisted they were. She took the medications, believing the physician might have changed her regimen upon admission, and subsequently blacked out and fell from her scooter. The clinical record included a progress note documenting that the resident fell as a result of a medication error and that her blood pressure was low, prompting contact with the nurse practitioner and transfer to the hospital. Hospital records showed the resident was admitted to the ICU for accidental ingestion of a muscle relaxant, an anticonvulsant, an anti-anxiety medication, and a blood pressure medication, and was followed for persistent bradycardia and hypotension requiring medications, oxygen, and intermittent vasopressor support. Facility staff interviews revealed that a CMA who was training another CMA removed medications for three residents, placed them in cups on top of the medication cart, and handed the keys to the trainee before going on break. The trainee then administered the medications, believing she was giving them to the intended resident, but was unaware there was a new resident in the same room and did not use the six rights of medication administration. The trainee acknowledged that the new resident did not yet have a photo in the EHR and admitted she did not follow the required resident identification and medication verification process. The facility’s policy required use of the resident photo in the MAR and adherence to the six rights of medication administration, which were not followed in this incident.
Failure to Follow Quetiapine Orders for a Resident With Behavioral Changes
Penalty
Summary
The facility failed to follow physician orders for a resident with anxiety disorder, depression, toxic encephalopathy, and moderately impaired cognition. The resident’s care plan identified a history of suicide attempt, episodes of behaviors, refusal of medications and cares, and attention-seeking behaviors. The care plan directed staff to administer medications as ordered, complete a medication review for behavior management, obtain a psychiatric consult, and observe and document behaviors. The resident’s admission medication orders included quetiapine 25 mg by mouth every night and 25 mg twice a day as needed, but the medication administration record showed multiple changes to quetiapine orders that were documented as PRN rather than scheduled. The MAR showed quetiapine PRN doses were given on several dates in November and only once in December, while a medication review later noted that the resident’s quetiapine 25 mg scheduled dose was not transferred to the orders on admission. A psychiatric assessment also documented psychosis and listed Seroquel 25 mg daily and Seroquel 50 mg at bedtime PRN. The resident had documented behavioral incidents during the stay, including grabbing a fire extinguisher, spraying it outside, and later shredding a roommate’s pillow with scissors. Progress notes described increased anxiety, a blank stare, shaking, refusal to speak with staff, and refusal to talk to the psychiatric provider. The resident was later sent to the hospital for altered mental status and unsafe behaviors, and the transfer form noted she had been rocking, stating she was scared, isolating herself, and recently refusing medications.
Catheter drainage bag raised above bladder during care
Penalty
Summary
Provide and implement an infection prevention and control program was not met when staff failed to follow catheter care practices during perineal care for a resident with a suprapubic catheter. Resident #16 had a BIMS score of 09 out of 15, diagnoses including quadriplegia, stroke, multidrug-resistant organism infection, abnormal bladder function, and obstructive uropathy, and required extensive assistance with ADLs and mobility. The care plan identified the resident as high risk for UTI due to suprapubic catheter use and directed staff to provide catheter care per protocol. During perineal care, two CNAs assisted the resident while he was lying in bed, and at the end of the procedure one CNA lifted the urinary drainage bag above the resident's bladder while putting on his shorts. The urine in the drainage tubing, which contained a white, mucoid substance, flowed back into the resident's bladder. The CNA later stated she had received IC training and knew the drainage bag and tubing should not be higher than the resident, and the DON stated staff should not have raised the drainage bag over the level of the resident's bladder. The facility policy directed staff to keep the drainage bag below the level of the bladder to discourage backflow of urine.
Failure to Administer Pneumococcal Vaccine After Consent
Penalty
Summary
The facility failed to provide the pneumococcal vaccine to 1 of 5 sampled residents reviewed for immunizations. Resident #12 was admitted on 9/25/25, was over age [AGE], and had diagnoses including cancer, sepsis, and respiratory failure. The MDS dated 10/2/25 identified the resident’s pneumococcal immunization as not up-to-date and indicated the vaccine was not received because it was not offered. The Iowa Registry Immunization System record scanned into the EHR showed the resident had not received a pneumococcal vaccine and listed the vaccine as past due. A Pneumococcal Vaccine Consent Form signed by the resident’s representative on 9/26/25 showed consent to receive the vaccine, and the EHR clinical immunization list showed Prevnar 20 as pending immunization. The immunization record lacked documentation showing whether the resident had ever received Pneumovax (PPSV23) or any pneumococcal conjugate vaccine, including Prevnar 20, Prevnar 21, or Vaxneuvance, per CDC guidelines. Progress notes from 9/25/25 through 12/22/25 documented a history of pneumonia but did not show that a pneumococcal vaccine was administered. Staff F, the ADON and Infection Preventionist, stated the facility offered flu and pneumonia vaccines, checked IRIS on admission, obtained consent or declination, and used standing orders, but also stated the resident had consented and requested the pneumonia vaccine and it was not given because the order was entered but not marked yes and was on the MAR but not administered.
Failure to Administer Consented COVID-19 Vaccine
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to 1 of 5 sampled residents reviewed for immunizations, Resident #20. The resident’s MDS assessment identified an admission date of 4/28/25 and diagnoses of sepsis and non-Alzheimer’s dementia. A COVID-19 Vaccine Consent Form dated 4/28/25 showed the resident gave consent to receive the COVID vaccine, but the EHR Clinical Immunizations tab showed only a COVID-19 booster last administered on 8/26/22. Review of the clinical record on 1/7/25 found no documentation showing whether Resident #20 had ever received the requested COVID vaccine. During interview, the ADON/Infection Preventionist stated she had worked at the facility since 6/2025 and in the Infection Preventionist role since 10/2025. She reported that she referenced CDC guidelines for COVID vaccine recommendations, checked the IRIS registry for resident immunization history, and that the facility had standing orders for immunizations. She stated the facility offered flu and pneumonia vaccines but had not gotten to COVID immunizations. She also reported that residents were offered immunizations on admission, consent or refusal was obtained, and the vaccine was obtained from the pharmacy. Later, she stated she was not employed when Resident #20 admitted, saw that the resident had consented and requested the COVID vaccine, but the vaccine was not given.
Failure to Respond to Change in Condition and Clarify Psychotropic Orders
Penalty
Summary
The facility failed to provide timely assessment and intervention for a resident who experienced a change in condition and was later hospitalized with sepsis, acute renal failure, acute hypoxic respiratory failure, and acute metabolic encephalopathy. The resident had diagnoses including COPD, heart failure, and diabetes, and the care plan directed staff to monitor and report symptoms such as fatigue, communication changes, and signs of discomfort or distress. Staff interviews and the record showed multiple observations of lethargy, altered mental status, reduced verbal response, difficulty swallowing, poor intake, and breathing concerns over the course of the day, but the progress notes did not document a change in status before the resident was sent to the hospital for altered mental status. The record and interviews showed that staff members observed the resident was not acting normally, including staring off, not talking much, appearing lethargic, having difficulty remaining upright, and eating and drinking very little. A CNA reported concerns to an LPN, and another nurse later noted the resident had a slight left-sided facial droop and was not talking right. The on-call provider’s note documented altered mental status, lethargy, possible facial droop, and that the resident had been symptomatic for about one day before transfer. The facility policy required prompt notification of the physician and resident representative for significant changes in condition, including deterioration in health or life-threatening conditions. The facility also failed to notify the provider to evaluate and review a 30-day psychotropic medication order for a new admission before the order expired. The resident had diagnoses including bipolar disorder, anxiety disorder, and memory impairment, and the care plan identified risk related to psychotropic drug use. Hospital discharge instructions included trazodone, quetiapine, and divalproex for 30 days, and the admission medication review specifically asked for clarification on whether the 30-day supply should be continued. The pharmacy medication regimen review also requested follow-up with the prescriber regarding the 30-day stop dates because the medications appeared to be maintenance medications, but the clarification was not documented, and the medications were stopped without tapering before being restarted later.
Failure to Remove Old Fentanyl Patch Before Applying New Patch
Penalty
Summary
The facility failed to follow the physician’s order to remove an old fentanyl patch before applying a new patch for a resident with cancer, polyneuropathy due to toxic agents, COPD, and unspecified abdominal pain. The care plan directed staff to administer fentanyl as ordered, and the physician’s order summary specified that a 25 mcg fentanyl patch was to be applied every 3 days, with the old patch removed before the new one was applied and sites rotated. The EMAR showed a 25 mcg patch applied on the left arm and, three days later, another patch applied on the right arm. Clinical records and interviews showed that after the second patch was applied, the resident became confused, lethargic, and unable to answer questions. Staff A, ARNP assessed the resident and noted lethargy and confusion, with a history of urosepsis and hydronephrosis, and sent the resident to the hospital. The EMS report documented that a fentanyl patch was removed en route to the hospital, and the ED physician noted that a second fentanyl patch was removed in the ED. The hospital discharge summary stated that on 9/7 the patient was transferred to the ICU for fentanyl overdose with severe acute hepatic encephalopathy and increased ammonia levels. Interviews indicated the nurse who applied the patch stated she removed the old patch before applying the new one, but she could not identify who witnessed the disposal or where it was documented. Staff A stated she did not look to see how many fentanyl patches were on the resident, though she heard there were two. The Administrator stated the nurse should have removed the prior patch before applying the new one and acknowledged that the ED notes showed two patches were present during transport. The facility policy on medication administration required medications to be given as ordered, and the controlled substance policy addressed disposal of removed patches but did not direct removal of old patches before applying a new patch.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance of a safe, clean, and comfortable environment. In one resident room, the carpet was excessively stained with dark and pink spills, and the bathroom shower was used for storage of trash bags filled with empty cans, while personal hygiene items were stored on the floor. The dining room had peeling paint, exposed drywall, and hanging plaster from water leaks, with one damaged area directly above a dining table. Additional findings included a large vent with dust buildup, stained ceiling tiles, windows with residue and tape marks, corroded sink cabinetry, and an actively leaking water line saturating the floor. The nurses' station and main facility areas had heavily stained carpets, and a skylight area had ceiling tiles with brown and black discoloration and powder-like particles falling onto the floor. The entertainment area vent was covered in a fuzzy, black substance, and the main carpeted areas were soiled with various stains. A resident who used a wheelchair was found to have a visibly soiled wheelchair with debris buildup and multiple cigarette burns on the cushion. The wheelchair's left wheel lock was nonfunctional, and the resident reported it had not worked properly for a long time. The DON confirmed that staff were expected to clean wheelchairs at least weekly and as needed, and that carpets had been shampooed multiple times without success in removing stains. Facility policy required housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, but these standards were not met as evidenced by the observations.
Failure to Provide Timely Response to Call Lights Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights for all residents reviewed, as evidenced by multiple resident interviews, observations, and record reviews. Several residents, all with significant care needs such as morbid obesity, heart failure, stroke, hemiplegia, and cognitive impairments, reported excessive delays in staff responding to their call lights, with some waiting over an hour and, in one case, over two hours. Residents consistently described situations where staff would turn off call lights, promise to return, and then not come back for extended periods, leaving residents without necessary assistance for toileting, transfers, and other essential care needs. Observations confirmed that call lights were not always accessible to residents, with instances where the call light was out of reach, preventing residents from requesting help. One resident was observed with the call light cord draped over the bed footboard and the button out of reach, and another resident confirmed they could not access the call light when needed. The facility's policy required call lights to be within reach and secured as needed, but this was not consistently followed. The Director of Nursing acknowledged that the policy did not specify a required response time but stated her expectation was for call lights to be answered within 15 minutes. Residents reported negative experiences due to these delays, including being left wet for extended periods, which contributed to ongoing skin issues, and having to leave their rooms to seek assistance themselves. The facility census at the time was 79 residents, and the deficiency was identified through a combination of resident interviews, staff interviews, observations, and policy review.
Widespread Infection Control Lapses During Resident Care and Dining
Penalty
Summary
Staff failed to maintain infection control practices for all residents reviewed, as evidenced by multiple observed lapses. During meal assistance, a CNA wore the same pair of gloves while touching multiple residents and their food items, without performing hand hygiene between contacts. In another instance, staff emptied a resident's catheter bag by placing the graduated container directly on the carpeted floor without a barrier and allowed the catheter drain spout to touch the inside of the container, contrary to facility policy. For another resident, although a barrier was used, the catheter spout repeatedly touched the inside of the graduated container during emptying, and the container was left uncovered on the back of the toilet after use. Additionally, a package of perineal wipes used for one resident was placed on another resident's bedside table after care was completed. Further deficiencies included a staff member providing ostomy care to a resident with a multidrug-resistant organism diagnosis without wearing a protective gown, as required by enhanced barrier precautions. It was discovered that PPE supply bins outside resident rooms were inadequately stocked, with only one out of several bins containing gowns. The DON confirmed expectations for proper hand hygiene, use of barriers, and PPE, which were not met during these observed care activities.
Incomplete Incontinence Care Provided
Penalty
Summary
Staff failed to provide complete incontinence care for a resident with a history of stroke, non-Alzheimer's dementia, and hemiplegia, who was dependent on staff for toilet hygiene and was always incontinent of urine and frequently incontinent of bowel. During observed care, staff removed a visibly wet brief and cleansed the area above the penis, the penis, and the scrotum, but did not cleanse the inner thighs. When the resident was turned, staff cleansed between the buttocks and inner buttocks but did not cleanse the outer buttocks and hips. Facility policy required cleansing of the buttocks and anus, and the Director of Nursing confirmed the expectation to cleanse all areas of the buttocks and hips during incontinence care.
Failure to Maintain Infection Control During Meal Service and Equipment Use
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during meal service and equipment use. Dietary staff were observed serving drinks and handling utensils by touching the rims of glasses and the spoon portions, then placing their hands in a trash bag and returning to serve residents without performing hand hygiene. This occurred repeatedly over a 25-minute period, with no hand sanitization between tasks. Additionally, a CNA was seen feeding residents by hand, touching food directly and placing it in residents' mouths without sanitizing hands or wearing gloves. The CNA also sneezed into her shirt, wiped her nose with her hand, and continued to serve food and drinks to residents without washing or sanitizing hands. Further, staff failed to clean and disinfect shared resident-care equipment, specifically an EZ Stand, between uses for different residents. The EZ Stand was moved from one resident room to another and parked in the hallway without being sanitized at any point during the observation. Facility policies require hand hygiene after sneezing, coughing, or handling food, and mandate cleaning and disinfection of reusable resident-care equipment between uses, but these procedures were not followed as observed.
Repeat Deficiencies Due to Ineffective QAPI Process
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies during the current recertification survey. Survey findings revealed that the facility had ongoing issues in several areas, including the development and implementation of comprehensive care plans, care plan timing and revision, accident hazards and supervision, labeling and storage of drugs and biologicals, staff competency, and infection prevention and control. These deficiencies were identified through staff interviews, review of CMS-2567 reports, and facility policy review. Repeated citations were documented across multiple surveys, with deficiencies noted for failing to develop and update care plans for residents prescribed medications such as insulin and antidepressants, as well as for residents with specific needs like smoking assessments and code status updates. There were also failures in ensuring appropriate supervision and interventions for residents at risk for accidents, falls, and elopement, as well as lapses in infection control practices, such as improper gloving and catheter care. The facility's QAPI policy outlined responsibilities for oversight and monitoring, but the recurrence of similar deficiencies indicated that the processes in place were not effective in preventing or correcting these issues. The CASPER report and survey history showed that the same types of deficiencies had been cited repeatedly over several years, including in previous annual recertification surveys. The facility's QAPI and QAA activities, as described in their policy, were intended to systematically identify and address problems, but the persistence of these deficiencies demonstrated that the facility did not adequately implement or sustain effective corrective actions to resolve the underlying issues.
Failure to Document Hospital Transfer, Notifications, and Bed Hold Notice
Penalty
Summary
The facility failed to document a resident's transfer to the hospital, including the required notifications to the physician and family, and did not provide documentation of a bed hold notice for one resident. Clinical record review showed that the resident, who had diagnoses of non-Alzheimer's dementia, stroke, and heart failure and was severely cognitively impaired, was on hospital leave for over two weeks. However, the resident's progress notes during this period lacked documentation of the transfer event, notifications to the physician and family, and completion of a bed hold notice. Further review of facility policy indicated that staff are required to obtain a physician's order for emergency transfers, provide necessary information to the receiving provider, document assessment findings and relevant information in the medical record, and provide a notice of transfer and bed hold policy to the resident and their representative. The Corporate Nurse confirmed that there was no documentation in the electronic health record regarding the assessment prior to transfer, bed hold notice, transfer information, or notifications to the physician and family, which was not in accordance with facility expectations.
Failure to Accurately Complete MDS Assessment for Serious Mental Illness
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for one resident by not identifying that the resident had a serious mental illness as determined by the state Level II Preadmission Screening and Resident Review (PASRR). Clinical record review showed that the resident's MDS, dated 3/22/25, listed diagnoses of psychotic disorder, anxiety disorder, and depression, but did not indicate that the resident was considered to have a serious mental illness by the PASRR process. However, the resident's PASRR Level II outcome, dated 1/20/24, confirmed that the resident met criteria for serious mental illness due to a diagnosis of major depressive disorder. Facility policy required accurate assessment and documentation of residents' medical, functional, and psychosocial problems. The Corporate Nurse confirmed the expectation that the MDS should be completed accurately.
Failure to Update PASRR Evaluation for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to submit an updated Preadmission Screening and Resident Review (PASRR) evaluation for a resident with multiple mental health diagnoses and psychotropic medications. Upon review, the resident's clinical record showed diagnoses including delusional disorders, non-Alzheimer's dementia, anxiety disorder, depression, psychotic disorder, and a history of substance abuse. The resident was also prescribed antipsychotic, antianxiety, and antidepressant medications, among others. Despite these significant mental health conditions and medication changes, the PASRR on file, dated at the time of admission, indicated no mental health diagnoses, symptoms, or related medications. The care plan for the resident was updated several times to reflect ongoing mental health concerns, behavioral symptoms, and the use of psychotropic medications. However, the PASRR was not updated to reflect these changes, as required by facility policy and federal regulations. Staff interviews confirmed that the PASRR in the electronic health record was the only one available and that no new PASRR had been submitted, even after the resident's diagnoses and medication regimen changed. Administration acknowledged that the PASRR should have been resubmitted when the care plan was updated to include new diagnoses and medications. Facility policy requires prompt referral for a Level II PASRR review when a resident exhibits new or possible serious mental disorders or when new information arises that refutes the original PASRR findings. In this case, despite clear evidence of new and ongoing mental health diagnoses and the use of psychotropic medications, the facility did not coordinate with the PASRR program to ensure an updated evaluation was completed, resulting in a failure to comply with regulatory requirements.
Failure to Develop and Implement Comprehensive Toileting Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including debility, cardiorespiratory issues, heart failure, diabetes mellitus, and respiratory failure. The resident was dependent on staff for personal care, including toileting hygiene, and was frequently incontinent of urine and always incontinent of bowel. Despite these needs, the care plan did not include specific interventions, tasks, or measurable goals related to toileting hygiene, assistance, or care. Staff interviews confirmed that the resident was not on a toileting program, and the Director of Nursing acknowledged that toileting interventions and steps were missing from the care plan. Observations over several days documented a persistent strong odor of urine in the resident's shared room, and staff reported inconsistent checks for incontinence episodes. Soiled clothing and briefs were found in the room, contributing to the odor. The facility's own policy requires comprehensive care plans with measurable objectives and timeframes to address all identified needs, but this was not followed for the resident in question.
Care Plan Not Updated After Resident's Clavicle Fracture
Penalty
Summary
The facility failed to revise the comprehensive care plan to accurately reflect the current status of a resident following a significant change in condition. The resident, who has diagnoses including hypertension, non-Alzheimer's dementia, anxiety disorder, and depression, was found on the floor after self-transferring from a wheelchair and subsequently diagnosed with a right clavicle fracture. The resident's care plan did not include the new diagnosis of a fractured right clavicle or the updated order for weight bearing as tolerated (WBAT) to the right upper extremity, despite documentation in the electronic health record and physician's orders. The resident's care plan continued to list interventions related to fall risk and mobility, but failed to address the specific needs and interventions required following the clavicle fracture and the new WBAT order. Staff interviews and facility policy review confirmed that the care plan should have been updated to reflect these changes in the resident's condition, as required by facility policy and regulatory guidelines.
Failure to Document and Implement Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated the necessary knowledge and techniques for timely medication management for a resident with multiple complex diagnoses, including cancer, heart failure, renal insufficiency, psychiatric disorders, and substance abuse. The resident was prescribed several psychotropic medications, and a pharmacist recommended a gradual dose reduction (GDR) for one of these medications, Mirtazapine. The recommendation was agreed upon by the facility's Nurse Practitioner, but there was no documentation indicating that the charge nurse received or processed the order, nor was there evidence of clarification or implementation of the GDR in the resident's medical record or Medication Administration Record (MAR). Interviews and record reviews revealed that the Director of Nursing (DON) was unaware that the recommended GDR had not been clarified or implemented, and the resident continued to receive the same dosage of Mirtazapine. The facility's medication order policy requires clear documentation, clarification, and transcription of medication orders, including changes in dosage, but these procedures were not followed in this case. This lapse resulted in a failure to ensure appropriate medication management and documentation for the resident.
Failure to Properly Store and Label Medications
Penalty
Summary
Surveyors observed a medication cart containing a medicine cup with approximately 12 pills labeled for a specific resident, which had been set aside because the resident preferred to take their medications later. A Certified Medication Aide confirmed this practice. Further inspection of the medication cart revealed unsealed or opened stock medications that were not labeled with the date they were opened. The Director of Nursing acknowledged that medications should not be pre-set and left in the cart, and that opened medications should be dated according to facility policy, which aligns with pharmacy recommendations. The facility's policy requires that the date be indicated on medications when the manufacturer's seal is broken by LTC personnel.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who had multiple complex medical conditions including atrial fibrillation, COPD, and respiratory failure, was assessed as requiring supervision while smoking, the use of a smoking apron, and for his lighter to be kept at the nurses' station. Despite these documented requirements, the resident was observed smoking independently in the outdoor courtyard without staff supervision, not wearing a smoking apron, and keeping his cigarettes and lighter in his wheelchair pouch. The resident confirmed he had not been supervised while smoking for some time, did not use the apron, and always kept his smoking supplies with him, contrary to the care plan and facility policy. Another resident, who had moderate cognitive impairment and significant mobility limitations due to multiple trauma, stroke, and multiple sclerosis, left the facility premises with a friend without notifying staff or signing out, as required by facility protocol. Staff discovered the resident was missing when his wheelchair was found outside by the drive, prompting a facility-wide search and calls to the resident's family and friend. The resident later returned and stated he was unaware of the need to inform staff or sign out when leaving, as this was not required in his previous assisted living setting. The resident's family also confirmed being contacted by the facility during the search. Both incidents demonstrate lapses in the facility's adherence to its own policies and care plans regarding resident safety and supervision. In the first case, the resident's smoking was not properly supervised according to the documented assessment and policy, and in the second case, the resident was able to leave the facility unsupervised despite his cognitive and physical impairments, and without following the required sign-out procedure. These failures resulted in the residents not receiving the level of supervision and environmental safety required to prevent accidents.
Failure to Assess and Manage Central Line for Resident
Penalty
Summary
The facility failed to provide appropriate assessment, obtain treatment orders, or ensure physician follow-up for a resident with a central venous catheter. Upon admission from an acute hospital, the resident, who had diagnoses including end stage renal disease, cirrhosis, and immunodeficiency, was noted to have a central line in the left internal jugular vein. However, the admission assessment and care plan did not identify the presence of the central line or include interventions for its care or infection prevention. Nursing progress notes documented the presence of the central line and a dialysis graft, but there was no evidence of physician notification or treatment orders for the central line, nor were there orders for monitoring, site care, or dressing changes in the medication and treatment administration records. Resident and staff interviews confirmed that the central line dressing had not been changed for an extended period, and staff were unsure of the line's purpose or management responsibility. The resident reported that the dressing appeared dirty and that staff discussed its condition, but no action was taken to address it until much later. The facility's policy required licensed nurses to notify physicians and obtain treatment orders in the absence of such orders, but this was not followed. The deficiency was identified through review of clinical records, staff and resident interviews, and facility policy.
Failure to Provide Competent Staff and Effective Care Planning for Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of a resident with a history of Substance Use Disorder (SUD). Direct care staff reported a lack of training specific to SUD, and the facility's behavioral health training did not include education on SUD. The care plan for the resident lacked a risk assessment for substance use, did not identify triggers or signs and symptoms to monitor for, and did not include interventions for suspected or identified substance use or plans for overdose emergencies. The facility's policy required staff to have education to meet the behavioral health needs of residents, including those with SUD, but this was not implemented in practice. A resident with a history of polysubstance abuse, including methamphetamines, marijuana, and alcohol, as well as diagnoses of Bipolar Disorder, Schizophrenia, and anxiety disorder, exhibited erratic and escalating behaviors during their stay. The resident had multiple incidents of agitation, paranoia, and threats of violence, resulting in hospitalizations and positive drug screens for methamphetamines and opioids. Staff interviews revealed that they had not received training on how to care for residents with SUD and were unsure how to respond to allegations or suspicions of substance use within the facility. Documentation showed that the resident's care plan interventions were limited to monitoring lab results, communicating facility rules, and offering information about substance use programs, but did not address specific strategies for prevention, monitoring, or response to substance use or overdose. Staff reported being told to keep the resident within sight but did not provide one-on-one supervision. The lack of targeted training and comprehensive care planning contributed to the facility's failure to effectively address the behavioral health needs of the resident with SUD.
Failure to Provide Diabetic Shoes Leads to Amputation
Penalty
Summary
The facility failed to ensure a resident with a history of bilateral foot diabetic ulcers received diabetic shoes as ordered by the physician. The order for diabetic shoes was placed on 7/10/24, but the facility did not follow up with the shoe vendor to ensure the shoes were ordered and delivered. This oversight continued throughout July, and by 8/30/24, the resident developed a foot ulcer, indicating a lack of preventative foot care measures. The resident, who had a history of Type 2 diabetes with foot ulcers and neuropathy, expressed a desire for diabetic shoes on 8/26/24. Despite this, the facility did not document any communication or follow-up with the shoe vendor between 7/10/24 and 8/30/24. The resident's condition worsened, leading to a wound on the left heel, which eventually required debridement and resulted in a left foot amputation on 10/26/24 and a below-the-knee amputation on 10/31/24. Interviews with facility staff and the shoe vendor revealed that the vendor requested additional paperwork to fulfill the shoe order, but the facility continued to send the same paperwork without addressing the vendor's request. The Director of Nursing stated that follow-up should occur within 24-48 hours, yet there was no evidence of such follow-up. The lack of timely action and communication contributed to the resident's deteriorating condition and subsequent amputations.
Removal Plan
- The DON and designee(s) conducted a full-house audit on diabetic residents to determine at-risk diabetics and ensure proper preventative foot care.
- An audit was conducted to ensure all treatments, supplies, and equipment were readily available for order by the physician and were being followed to ensure residents received the proper preventative foot care.
- DON or designee(s) reviewed the medical records of diabetic residents to ensure that weekly skin assessments were completed and treatment recommendations/orders were in place.
- The DON or designee conducted a care plan audit to ensure that treatment recommendations/orders were included in the care plan and that they were being followed.
- All facility policies and procedures related to podiatry services, skin integrity foot care, and physician orders reviewed and revised as needed.
- Education provided to regional Clinical Manager at Curana to ensure that all practitioners that come to Pine Acres will be collaborating with the IDT team to ensure referrals are made timely and appropriately.
- An audit of orders, interventions, and devices regarding foot care and foot services was conducted by the Nursing Supervisor(s) to ensure proper use.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on facility policies and procedures related to diabetes, foot care, and appropriate wound treatment measures.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on appropriate documentation, which included transcription and entering treatment orders on the physician's order sheet in the EHR and the resident's TAR.
- DON/Corporate Nurse/Consultant educated all nurse aides on preventative diabetic foot care.
- DON/Corporate Nurse/Consultant conducted daily treatment record and nursing documentation audits to ensure accurate and complete documentation of diabetic foot care and preventative measures.
- For residents returning from the hospital, treatment recommendations/orders and wound care appointments will be transcribed and overseen by the DON and Corporate Nurse.
- DON/Corporate Nurse/Consultant Monitoring will continue to monitor/audit the following: Observation of treatments for diabetic foot care prevention and orders, Weekly physician orders, Weekly diabetic skin treatment orders related to diabetics, Treatment recommendations and orders are being added and processed into the EHR and TAR.
- A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue.
Failure to Update Care Plans for Advance Directives and Smoking Status
Penalty
Summary
The facility failed to fully review and revise the comprehensive care plans for several residents following changes in their advance directives and smoking status. Specifically, discrepancies were found between the Iowa Physician Orders for Scope of Treatment (IPOST) and the care plans for multiple residents. For instance, one resident's IPOST indicated a Do Not Attempt Resuscitation (DNR) status, while their care plan listed them as Full Code, requiring emergency measures like CPR. Another resident's care plan did not reflect their Full Code status as indicated in their IPOST. Additionally, the facility did not update care plans to reflect changes in residents' smoking status and safety measures. One resident's care plan failed to include the requirement to wear a smoking apron, despite the smoking assessment indicating this safety measure. Another resident's care plan did not document their approval to use a vape and the prohibition of cigarette smoking due to safety concerns. Furthermore, a resident was observed smoking without a completed smoking assessment or any interventions documented in their care plan. Interviews with facility staff, including the Social Worker, Director of Nursing (DON), and MDS Coordinator, revealed that there were established procedures for updating care plans upon changes in residents' status. However, these procedures were not consistently followed, leading to the deficiencies noted. The facility's policies on residents' rights regarding treatment and advance directives, as well as smoking policies, were not adequately implemented, resulting in incomplete or inaccurate care plans for the affected residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 394 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Des Moines
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Iowa Jewish Senior Life Center | 2.1 mi | ★★★★★ | 20 | 0 |
| Karen Acres Care Center | 2.5 mi | ★★★★★ | 2 | 0 |
| Walnut Ridge | 2.8 mi | ★★★★★ | 0 | 0 |
| Calvin Community | 2.9 mi | ★★★★★ | 12 | 0 |
| Wesley On Grand | 3.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Pine Acres Rehabilitation And Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.