Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Pinnacle Specialty Care during CMS and state inspections, most recent first.
Failure to Timely Report Allegation of Abuse: The facility did not timely submit a self-report for an allegation involving a resident with intact cognition, recent surgery, wound care needs, HF, DM, and a hip fracture. A representative alleged negligent care and reported that wraps were left on overnight, were too tight, and caused bruising and blisters; the DON also documented provider follow-up and the daughter’s concern about the resident’s foot. The facility later recognized that a self-report should have been filed for the allegation, but it was submitted late instead of immediately as required by policy.
A resident with intact cognition, anxiety, DM2, and OA had a care plan requiring two-assist bed mobility and two-assist care in pairs for toileting/incontinent care, but staff did not follow it during brief changes. Records and staff interviews showed a CNA provided care alone on overnight shifts, while the resident later reported feeling a knuckle in her back during care and said she is very sensitive to touch. An LPN and the DON confirmed the resident required two staff members, and the CNA’s file showed she had been trained to review and follow care plans.
Delayed response to activated call lights was identified when two residents reported waiting up to 2 hours for help, and observations showed call lights unanswered for more than 15 minutes. One resident with moderately impaired cognition and ADL assistance needs was observed waiting to be taken to the bathroom, while another resident with intact cognition and a fall risk reported repeated delays with toileting assistance. Staff stated a 15-minute response time was appropriate, but the facility policy did not define a specific timely response standard.
A resident with chronic pain received an extra opioid dose instead of the ordered PRN analgesic, and the MAR did not reflect the second administration or required monitoring. The resident later required ER evaluation after the opioid error was discovered. Another resident reported missed midday and afternoon meds, but the MAR showed them as given even though staff later said the resident was unavailable and the documentation was inaccurate.
The facility failed to show good faith efforts to correct repeat quality deficiencies during the survey process. The CMS 2567 showed a prior F725 for insufficient nursing staff, and the ADON reported ongoing call light audits and on-the-spot education when staff were observed sitting at the nurse’s station while active call lights were present. The QAPI policy required the committee to analyze data, identify and resolve quality problems, use root cause analysis, and help implement systems to correct issues.
Surveyors found that the facility failed to maintain an adequate supply of ordered and stock OTC medications and did not consistently document reasons for missed doses. One resident missed multiple doses of an iron supplement and another missed several doses of Loratadine, with MAR entries marked as not given and no clarifying progress notes. Staff, including an RN, CMA, and LPN, reported that medications such as Miralax, lidocaine patches, sennosides, and APAP were out of stock for multiple days, and one CMA was unsure if physicians were notified when medications were unavailable. The ARNP stated she was not informed about unavailable stock medications, while the DON confirmed that a specific EMAR code indicated drugs were not given and referenced a weekly medication check process despite a policy requiring timely ordering to ensure medications are on hand.
A resident with cognitive impairment, Parkinson’s disease, polyneuropathy, and a leg fracture developed a buttock pressure ulcer after being identified as at risk for skin breakdown. Although providers ordered multiple new treatments, including topical agents, specialized wound care, dietary protein supplements, an air mattress, and strict bed rest with limited time up in a wheelchair, the care plan was not updated to reflect these changes. Staff and the resident reported that the resident frequently refused to lie down, remained in a wheelchair for long periods, directed her own care, and declined equipment changes, yet these refusals and self-directed care decisions were not incorporated into the care plan, nor were the facility’s attempts to adjust wheelchairs and implement pressure-relief measures documented.
A resident with multiple comorbidities and a PICC line did not receive a scheduled transparent semi-permeable membrane (TSM) dressing change as ordered and per facility policy. The EMAR lacked documentation of the due dressing change, and repeated observations showed the same PICC dressing in place without a date or nurse initials, while the resident reported that only line flushing had been performed. The ARNP and DON both stated that PICC dressings were expected to be changed weekly and as needed, consistent with facility policy requiring TSM dressing changes every 5–7 days, but they were unaware the scheduled dressing change had been missed until later.
A resident with intact cognition and multiple comorbidities, including DM with kidney complications, CHF, seizures, and schizophrenia, routinely left the facility for dialysis without staff completing or documenting pre-dialysis assessments. The resident reported that vitals were not checked before departure, and an RN confirmed no assessment was done and that she had not been educated on dialysis assessments. The DON stated that pre-dialysis assessments should include weight, VS, and fistula site observation with documentation in the EHR, but the facility’s ESRD policy lacked specific guidance on pre- and post-dialysis assessments.
A resident with moderate cognitive impairment and dependence for transfers was lowered to the floor after a CNA attempted the transfer with only one assist, despite the resident stating that two staff were needed. The incident was not reported to nursing staff at the time, and the resident was not assessed by a nurse when it occurred. His care plan required two staff for transfers.
Delayed response to activated call lights. A resident who needed assistance with toileting and transfers reported waiting 1.5 to 2 hours for call lights to be answered and said she used a timer to track staff response. Surveyors observed an activated call light remain unanswered for 18 minutes while a CNA, a CMA/CNA, and an LPN passed by the room, and staff gave differing expectations for response time while the facility policy did not define timely response.
Surveyors found that several dining room chairs remained dirty with dried food and spilled drinks over multiple days, despite being used by residents. Housekeeping staff reported inconsistent cleaning routines and unclear responsibilities, and facility policy lacked specific guidance on cleaning frequency or departmental duties.
A resident's MDS assessment was found to be incomplete, as it failed to include a documented diagnosis of PTSD despite psychiatric notes indicating its presence. The assessment did record other mental health conditions and an intact BIMS score, but the omission of PTSD was confirmed by the administrator as a documentation oversight.
The facility did not complete new PASRR evaluations for two residents with multiple mental health diagnoses, despite documentation of ongoing behavioral symptoms and medication use. One resident's records lacked evidence of a new PASRR after a short-term approval expired, and another resident's PASRR did not reflect all current diagnoses, with no update submitted despite changes in condition.
A resident's care plan was not updated to include PTSD and a history of suicide, despite these being documented in psychiatric notes and physician recommendations. Staff confirmed that the care plan should have reflected these mental health needs.
A facility failed to notify the LTC Ombudsman about a resident's multiple hospital transfers, as required by federal regulation. The Social Worker responsible for notifications admitted to not informing the Ombudsman, assuming it was being done. The DON confirmed the absence of a specific policy for such notifications, stating they follow regulations.
A resident with a fracture and intact cognition received inconsistent bathing care, with only one bed bath documented in two weeks. Despite requiring assistance due to an immobilizer on her left leg, facility records inaccurately reflected her bathing schedule, with staff admitting to documentation errors. The resident reported not being informed about her bathing schedule, and an internal investigation revealed discrepancies between witness statements and electronic health records.
A resident with severe cognitive impairment and multiple health conditions was not provided the correct mechanical soft diet as prescribed. Despite being ordered a diet requiring ground or finely chopped food, the resident was served inappropriate food textures, such as a chicken leg with bone and unground ham. The Dietary Manager acknowledged the oversight, and photographic evidence supported the claims of non-compliance with diet orders.
A resident with a leg fracture and intact cognition experienced a deficiency in care when the facility failed to address non-functional wheelchair brakes, despite being aware of the issue. Staff continued to transfer the resident without repairing or replacing the wheelchair, and no work order was documented for maintenance. The Director of Nursing acknowledged the concern but noted a lack of specific policy addressing the issue.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse for 1 of 2 residents reviewed, Resident #33. Resident #33’s MDS assessment documented a BIMS score of 13, indicating intact cognition, with no hallucinations or delusions. The assessment also noted occasional urinary incontinence, a recent surgery requiring surgical wound care, and diagnoses of heart failure, diabetes mellitus, and hip fracture. The care plan identified skin impairment to a surgical hip and a blister to the top of the left foot, with interventions to educate the resident, family, and caregivers about preventing skin injury, monitor and document the skin injury, and apply Tubi grips from knees to toes in the morning and remove them in the afternoon. A grievance/concern investigation form dated 4/29/26 documented a representative’s allegation of negligent care, and another form dated 4/30/26 alleged the facility did not follow wound orders and left wraps on all night, causing them to be too tight and cut off blood circulation, leaving bruises and blisters. The Traveling DON documented the provider saw Resident #33 on 4/28/26 and again on 4/30/26, and a social service note documented the daughter’s concern about the resident’s foot. Facility self-reports showed an incident dated 4/15/26 was filed on 5/28/26 as “other,” and the Area Administrator stated on 5/28/26 that after reviewing the grievance form, she realized a facility self-report should have been submitted for an allegation of abuse that occurred in April 2026. The facility’s policy required suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source to be reported immediately and the investigation results to be provided within five working days.
Failure to Follow Comprehensive Care Plan for ADL Assistance
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #22, whose MDS documented a BIMS score of 15, anxiety disorder, type II diabetes mellitus, and osteoarthritis. The resident received scheduled pain medications and had occasional pain during the five-day look-back period. The care plan initiated on 7/25/24 identified an ADL focus area with interventions for two-assist bed mobility, two-assist with a mechanical lift when toileting, and care provided in pairs initiated 5/14/26. Facility records and staff interviews showed that the care plan was not followed during incontinent care. The Documentation Survey Report V2 for April 2026 showed a CNA provided bowel and bladder elimination care on two overnight shifts. Resident #22 later reported that a CNA changed her brief and that she felt a knuckle in her back, which she reported to the Interim Administrator; she stated she was very sensitive to touch. The CNA reported she was the only CNA scheduled on the unit and admitted no other staff were in the room when she changed the resident’s brief, while also stating the resident required two staff members. An LPN and the Traveling DON both confirmed that Resident #22 required two staff members for care in pairs and for bed mobility, and the CNA’s personnel file showed she had been trained to review and follow care plans.
Delayed Response to Activated Call Lights
Penalty
Summary
The facility failed to consistently respond to activated call lights within a reasonable amount of time. Residents reported waiting up to 2 hours for call lights to be answered, and observations showed response times greater than 15 minutes for 2 residents. The facility had a census of 92. Resident #35 had a BIMS score of 11, indicating moderately impaired cognition, and required assistance with toileting hygiene and toilet transfers. His care plan directed staff to assist with ambulation, toileting, and transfers, and to encourage use of the call light for assistance. On observation, he was sitting in his wheelchair outside his room and stated he had been waiting for someone to take him to the bathroom and needed to go now. The call light monitor later showed a bed E-call for his room with an age of 44 minutes and 16 seconds at the eighth resound. Resident #12 had a BIMS score of 15 and required partial/moderate assistance with toileting hygiene and toilet transfers. Her care plan identified a fall risk related to weakness, seizures, and a prior fall with left hip fracture, and directed staff to educate her to use her call light for assistance. The call light monitor showed a bath E-call for her room with an age of 15 minutes and 58 seconds at the third resound. She reported that staff sometimes took a long time to respond and described an episode about 2 to 3 weeks earlier when she waited 2 hours for help to use the bathroom. Staff stated an appropriate response time to an activated call light was 15 minutes, while the Traveling DON acknowledged the facility policy did not define a targeted response time even though regulations state 15 minutes is appropriate. The facility's call light policy described how alarms display age and re-alarm every 5 minutes, and the answering call light policy required timely response, but it did not define what constitutes a timely response.
Medication Administration Errors and Inaccurate MAR Documentation
Penalty
Summary
The facility failed to administer medications in accordance with physician orders and failed to maintain accurate MAR documentation for two residents. One resident had intact cognition, multiple sclerosis, quadriplegia, anxiety disorder, and chronic pain, and was ordered morphine sulfate ER 30 mg every 8 hours for pain plus hydrocodone-acetaminophen 5-325 mg every 12 hours as needed. On 5/19/26, staff documented morphine at 4:20 PM and again at 8:00 PM, but the MAR did not reflect the 8:00 PM dose. The record also lacked documentation of non-pharmacological pain interventions before the medication was given and lacked documentation of monitoring for side effects after the second dose. The clinical record and staff interviews showed the second morphine dose was given in error instead of the ordered PRN hydrocodone-acetaminophen. The extra dose was discovered during the narcotic count later that evening, and the resident’s vital signs showed low blood pressure and oxygen saturation of 85% on 4 liters of oxygen. The resident was sent to the emergency room for evaluation, and the hospital record documented accidental opioid poisoning/overdose after the extra morphine dose. Staff stated the error was not charted in the MAR and that personal notes were used instead of the EHR, leaving the medication administration record incomplete and inaccurate. A second resident with intact cognition, cerebral palsy, seizure disorder, and memory/recall problems reported not receiving midday and 4:00 PM medications on 5/8/26. The MAR showed those medications as given, including lurasidone, artificial tears, and gabapentin, but the resident stated she was not in the room and did not leave the facility that day. Staff later stated the medications had been prepared but the resident could not be found, and the documentation was later corrected. The progress notes lacked documentation of the missed medications or physician notification for the omitted doses.
QAPI Process and Repeat Quality Deficiency
Penalty
Summary
The facility failed to demonstrate good faith attempts to correct quality deficiencies related to repeat deficiencies identified during the current survey process and corrections that remained incomplete within a reasonable time frame. Review of the CMS Form 2567 showed the facility had previously received deficiency F725 for insufficient nursing staff, with a correction date of 11/29/25. During the current survey, the Assistant Director of Nursing reported that the facility was continuing to monitor call lights through audits and stated that staff were educated on the spot when surveyors observed staff sitting at the nurse’s station while active call lights were present. The facility’s QAPI Program - Governance and Leadership policy, revised March 2020, stated that the QAPI Committee is responsible for collecting and analyzing performance indicator data, identifying and resolving negative outcomes and care quality problems, using root cause analysis, and helping departments implement systems to correct quality issues.
Failure to Maintain Adequate Medication Supply and Documentation
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to failure to ensure that ordered medications and stock OTC drugs were available and administered as prescribed. Record review showed that one resident did not receive ordered Poly-Iron 150 mg capsules on multiple specific dates in March 2026, with staff documenting a code of 9 on the MAR for those dates. The resident received all other medications as scheduled on those days, and the associated progress notes did not clarify why the iron supplement was not given. Another resident had an order for Loratadine 5 mg daily for prophylaxis, but the January 2026 MAR showed multiple dates where the medication was not administered, again marked with a code of 9 and without explanatory documentation in the progress notes. Staff interviews confirmed that a code of 9 on the EMAR meant the medication was not given and that staff were instructed to chart on order rather than chart drugs as not available. Multiple staff, including an RN, CMA, and LPN, reported that the facility had been out of stock medications such as Miralax, lidocaine patches, sennosides, and acetaminophen for multiple days at a time. One CMA stated she did not know if anyone notified the physician when medications were unavailable, while an LPN reported she would notify the physician to see if an alternative could be used. The ARNP stated she was not informed when stock medications were unavailable and noted that sometimes ordered wound treatments were still not available a week later. The DON acknowledged that a 9 on the EMAR meant the drug was not given and referenced a process of checking and ordering medications weekly, while the facility’s policy required transmitting requests for non-prescription medications and supplies early enough to ensure necessary medications were on hand at all times.
Failure to Revise Care Plan for Pressure Ulcer Management and Bed Rest Non-Compliance
Penalty
Summary
The deficiency involves the facility’s failure to revise and update a resident’s care plan to address new skin integrity issues and persistent non-compliance with prescribed bed rest. The resident had moderately impaired cognition with a BIMS score of 10 and diagnoses including Parkinson’s disease, polyneuropathy, and a left fibula fracture. An MDS assessment identified the resident as at risk for pressure ulcers, and an existing care plan focus for potential/actual skin integrity impairment included general interventions such as avoiding scratching, using a wheelchair cushion, providing education, encouraging nutrition and hydration, identifying causes of skin issues, following treatment protocols, using a pressure-relieving mattress, and providing treatments per provider orders. Subsequently, the resident developed a new pressure area on the buttocks, and multiple new medical orders and clinical directions were issued, including zinc oxide, Calmoseptine, frequent repositioning, use of a wheelchair cushion, a wound clinic referral, Santyl treatments, and bed rest with being up only for meals and PT. The wound clinic later reiterated that the resident should be up for meals only and then returned to bed immediately, and additional orders were obtained for antibiotics, vinegar soaks, and continuation of Dakin’s solution due to wound infection. The dietitian also recommended protein supplements and extra eggs because of wound deterioration. Despite these developments and changes in the resident’s condition and treatment regimen, the care plan was not revised to incorporate these new wound care orders and related interventions. Interviews with the resident, nursing staff, CNAs, the ARNP, and the DON showed that the resident frequently refused to lie down during the day, remained in the wheelchair for extended periods, and directed her own care, including refusing changes to her wheelchair and declining to comply with bed rest instructions except when influenced by her daughter. Staff reported that the resident was not good at staying on her side, needed reminders to reposition, and routinely stayed in her wheelchair from breakfast to lunch or longer despite medical advice to limit time out of bed. The care plan, when reviewed, lacked documentation of the facility’s attempts to find alternate wheelchairs, the implementation of an air mattress, the resident’s ongoing refusal to lie down, and her decisions to self-direct her care, resulting in a failure to update the care plan to reflect her current needs, behaviors, and provider-directed interventions related to skin integrity and pressure ulcer management.
Missed PICC Line Dressing Change and Lack of Documentation
Penalty
Summary
The deficiency involves the facility’s failure to perform a scheduled Peripherally Inserted Central Catheter (PICC) line dressing change in accordance with professional standards and facility policy for one resident. The resident had multiple medical diagnoses, including cellulitis of the buttock, anemia, heart failure, renal insufficiency, diabetes mellitus, and hidradenitis suppurativa, and the MDS documented that a PICC line was in place. The EMAR did not contain documentation that the transparent semi-permeable membrane (TSM) dressing change, scheduled for 3/30/26, was completed. On 3/31/26, the resident reported that staff flushed the PICC line but did not change the dressing, and observation of the PICC site at that time showed a dressing without a date or nurse initials. A subsequent observation on 4/1/26 again showed the same undated, uninitialed dressing still in place. On 4/2/26, the ARNP stated that the expectation was for the PICC dressing to be changed weekly and was unaware that the weekly dressing change had not been completed. Later that morning, observation showed the PICC dressing now dated 4/1/26 with nurse initials, and the resident stated the dressing had been changed the previous day. The DON confirmed that PICC dressings were to be changed weekly and as needed and stated she did not become aware that the 3/30/26 treatment had not been done until 4/1/26. Facility policy on Central Venous Catheter Dressing Changes, revised April 2016, directed staff to change TSM dressings at least every 5 to 7 days and as needed if wet, soiled, or not intact.
Failure to Perform and Document Pre-Dialysis Assessments
Penalty
Summary
The deficiency involves the facility’s failure to complete required pre-dialysis assessments for a resident who routinely received dialysis treatments. The resident’s MDS documented intact cognition with a BIMS score of 14 and multiple diagnoses, including type 2 DM with kidney complications, anxiety, hypertension, depression, schizophrenia, seizures, and heart failure, and confirmed that the resident received dialysis. Review of the EHR for March 2026 showed no documentation of any pre-dialysis evaluations for this resident. The resident reported that staff did not check her vital signs before she left for dialysis. A RN stated that the resident left the facility around 3:30 AM on dialysis days and acknowledged that she did not complete an assessment before the resident’s departure, further noting she had never received education on a dialysis assessment. The DON stated her expectation that a dialysis assessment would include obtaining the resident’s weight and vital signs, observing the fistula site for signs and symptoms of complications, and documenting the evaluation in the EHR. Review of the facility’s ESRD Care of a Resident policy showed it addressed general care for residents receiving dialysis but did not include directions for completing pre- and post-dialysis assessments.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate nursing supervision and follow-up assessment for a resident who required two staff members for transfers. Resident #4’s MDS documented moderate cognitive impairment, dependence on staff for chair or bed-to-chair transfers, and diagnoses of cancer, malnutrition, and septicemia. His care plan directed staff to use two staff for transfers, but a CNA transferred him with only one assist after the resident told her that another person was needed. The resident was then lowered to the floor during the transfer. The incident was not reported to nursing staff at the time it occurred, and the resident was not assessed by a nurse when he was lowered to the floor. The resident later stated that he told the CNA she could not do the transfer alone, but she did not listen and had to lower him to the floor. The facility’s records also documented that the resident’s wife later reported the event, and the care plan continued to identify the need for two staff for transfers.
Delayed response to activated call lights
Penalty
Summary
The facility failed to consistently respond to activated call lights within a reasonable amount of time and did not have a licensed nurse in charge on each shift as reflected in the survey findings. Residents reported waiting 1.5 to 2 hours for call lights to be answered, and the facility’s census was 93. The report also noted that the expectation for activated call light response was stated by the Administrator as 15 minutes or less, while staff interviews reflected different understandings of the expected response time. Resident #7 was assessed as needing partial/moderate assistance with toileting hygiene and toilet transfers, had a BIMS score of 15 indicating intact cognition, and the care plan indicated she required 1 assist for toileting and transfers and used a walker and wheelchair for mobility. During observation, the lighted hall display showed Bath 308 ecall activated, and Resident #7 stated she had waited about 10 minutes after activating her call light and had previously waited 1 1/2 to 2 hours for staff to respond. She reported transferring herself to the toilet and using a timer to monitor staff response, and said she reactivated the system when her timer reached 15 minutes. Survey observations showed the activated call light remained unanswered while Staff A, a CNA, walked past the room after exiting another resident room, and Staff B, a CMA/CNA, and Staff C, an LPN, also passed by without entering. The nurses’ station monitor showed the call light had been active for 18 minutes and was on its third resound before Staff A entered the room to assist Resident #7. Staff interviews indicated response times of within 5 minutes, within 5 to 12 minutes, and within 15 minutes or less, while the facility policy required timely response but did not define timely response. The report also noted call light audit records identified two call lights exceeding 15 minutes and that the audit report lacked the identified room of 308.
Failure to Maintain Clean and Homelike Dining Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, comfortable, and homelike environment in the dining room, as evidenced by multiple instances of dried food and spilled drinks on several chairs over a three-day period. Despite daily use by residents, including during group exercise, the chairs remained visibly dirty, with a total of 17 chairs noted as unclean. Interviews with housekeeping staff revealed inconsistent cleaning practices, with responsibility for cleaning the dining room chairs unclear and varying depending on which staff were present. The facility's policy on dining room audits did not specify the frequency of chair cleaning or designate which department was responsible for this task, contributing to the ongoing issue.
Failure to Accurately Document Resident Diagnoses in MDS Assessment
Penalty
Summary
The facility failed to accurately document and submit a complete Minimum Data Set (MDS) assessment for one resident. Clinical record review and staff interviews revealed that the MDS assessment for this resident recorded a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition, and included diagnoses of anxiety, depression, and bipolar disorder. However, the MDS did not include a diagnosis of Post Traumatic Stress Disorder (PTSD), despite both the initial and current psychiatric progress notes documenting PTSD as a diagnosis. The administrator confirmed that Social Services should have reviewed the psychiatric notes to ensure all correct diagnoses, including PTSD, were reflected in the MDS.
Failure to Complete Required PASRR Evaluations for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to complete new Preadmission Screening and Resident Review (PASRR) evaluations as required for two residents. For one resident, the Minimum Data Set (MDS) assessments documented diagnoses of anxiety, depression, and bipolar disorder, with a PASRR short-term approval that had an end date. The electronic health record lacked documentation of a new PASRR being completed, and there was no evidence in the progress notes of efforts to move the resident toward discharge to a lower level of care before the short-term approval expired. Additionally, psychiatric progress notes included a diagnosis of PTSD that was not reflected in the PASRR documentation. The administrator confirmed that social services were responsible for PASRR assessments and acknowledged the deficiency was identified during a mock survey, but a new PASRR had not yet been completed. For the second resident, the MDS assessment included multiple mental health diagnoses and documented the use of antipsychotic and antidepressant medications. The care plan identified behavioral problems and risks related to medication side effects. The medical diagnosis sheet listed several mental health conditions, but the PASRR Level 1 screen only included an unspecified mood disorder and indicated no PASRR disability was present. The rationale for not updating the PASRR was based on the absence of a status change, despite the presence of multiple mental health diagnoses and behavioral symptoms.
Failure to Update Care Plan for Mental Health Diagnoses
Penalty
Summary
The facility failed to revise the care plan for one resident to include documentation and interventions for Post Traumatic Stress Disorder (PTSD) and a history of suicide. Clinical record review showed that the resident had a documented diagnosis of PTSD in psychiatric progress notes and a history of severe depression with a suicide attempt, as noted in physician recommendations. However, the resident's care plan, last revised on 4/2/25, did not reflect these mental health needs. Staff interviews confirmed that the care plan should have included PTSD and the history of suicidal ideations, and that the social services coordinator should have updated the care plan based on physician notes.
Failure to Notify Ombudsman of Resident's Hospital Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care (LTC) Ombudsman regarding the hospital transfers of a resident, identified as Resident #65. The clinical record review revealed multiple instances where the resident was discharged to the hospital and subsequently returned to the facility, specifically on five occasions. However, there was no documentation indicating that the Ombudsman was notified of these discharges, as required by federal regulation. During an interview, the facility's Social Worker, who is responsible for sending such notifications, admitted to not notifying the Ombudsman about the resident's hospital discharges, assuming that the notifications were being sent. Additionally, the Director of Nursing confirmed that the facility did not have a specific policy for notifying the Ombudsman and stated that they follow regulations.
Inconsistent Bathing Care for Resident with Fracture
Penalty
Summary
The facility failed to provide consistent bathing care for a resident, identified as Resident #140, who only received one bed bath in the two weeks following her admission. Resident #140, who was admitted from a short-term general hospital stay, had a BIMS score indicating intact cognition and required partial/moderate assistance for bathing due to a fracture and pain in her left leg. The care plan specified the need for an immobilizer on her left leg and assistance from one staff member for bathing. Despite these requirements, the facility's documentation showed that Resident #140 only received a bed bath on one occasion, with other entries marked as not applicable or indicating refusal without proper follow-up. Observations and interviews revealed discrepancies in the documentation and communication regarding Resident #140's bathing schedule. On one occasion, a staff member attempted to remove the resident's brace for a shower, but the resident expressed discomfort and opted for a bed bath instead. The facility's point of care records inaccurately documented the resident's bathing activities, with staff members admitting to errors in recording and failing to offer showers as required. The resident reported not being informed about her bathing schedule and expressed concerns about the lack of consistent care. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) conducted an internal investigation, which included obtaining witness statements from the resident. These statements conflicted with the electronic health records, as the resident claimed to receive bed baths every night, contrary to the documented evidence. The DON acknowledged the inconsistencies in the documentation and the resident's report of only receiving two bed baths since admission. The facility's policy on bathing, revised in 2018, emphasized the importance of documenting bathing activities and addressing refusals, which was not adhered to in this case.
Failure to Provide Correct Diet Texture for Resident
Penalty
Summary
The facility failed to provide the correct diet to a resident with severe cognitive impairment and multiple health conditions, including malnutrition and esophageal obstruction. The resident was prescribed a mechanical soft diet, which requires food to be ground or finely chopped to accommodate difficulty in chewing and swallowing. However, the resident was served food that did not meet these requirements, such as a chicken leg with bone intact, unground ham, and fish fillets. The resident's family member reported these incidents to the facility's administrator, who did not recall the grievance but acknowledged the importance of adhering to diet orders. The Dietary Manager confirmed that the resident's diet should have been mechanical soft, with all meats ground and fish cut into small pieces. The manager admitted that the cook might not have followed the diet order, leading to the resident receiving incorrect food textures. Photographic evidence provided by the family member supported these claims, showing meals that did not comply with the mechanical soft diet. The facility's policy required adherence to physician diet orders, but this was not followed, raising concerns about the risk of choking for the resident.
Failure to Address Wheelchair Brake Malfunction
Penalty
Summary
The facility failed to provide necessary safety interventions for a resident, identified as Resident #140, whose wheelchair brakes were not functioning. Despite being aware of the issue, the facility continued to transfer the resident in and out of the wheelchair without repairing the brakes or replacing the wheelchair. This oversight persisted even though the resident had expressed concerns about the malfunctioning brakes and the potential risk of falling. Resident #140, who had been admitted from a short-term general hospital stay, had a fracture and pain in her left leg, requiring an immobilizer and toe touch weight bearing on her left lower extremity. The resident was cognitively intact and required moderate assistance for activities of daily living. During an orthopedic appointment, the resident was advised to inform the facility about the non-functional brakes, which she did not initially do. However, staff members were aware of the issue, as they had been using their foot to stop the wheelchair from rolling during transfers. Despite discussions among staff about the need to fix the wheelchair brakes, no work order was documented or submitted to the maintenance department. The maintenance supervisor confirmed that no work order was received, and thus, no repairs were made. The Director of Nursing acknowledged the concern but indicated that the facility's policy did not specifically address the issue of non-functioning wheelchair brakes, highlighting a gap in the facility's procedures for ensuring resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedar Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Suites At Western Home Communities | 0.3 mi | ★★★★★ | 1 | 0 |
| Newaldaya Lifescapes | 1.8 mi | ★★★★★ | 1 | 0 |
| Martin Health Center, Inc | 2.7 mi | ★★★★★ | 0 | 0 |
| Cedar Falls Health Care Center | 3.3 mi | ★★★★★ | 20 | 0 |
| Harmony House Health Care Center | 3.4 mi | ★★★★★ | 19 | 0 |
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