Tabor Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tabor, Iowa.
- Location
- 209 Main Street, Tabor, Iowa 51653
- CMS Provider Number
- 165546
- Inspections on file
- 25
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Tabor Manor Care Center during CMS and state inspections, most recent first.
A medication cart containing gabapentin, escitalopram, and multiple antihypertensives was observed unlocked at the nurses’ station facing the lobby while the RN assigned to it was across the lobby with her back partially turned and her view blocked by a vase of flowers. During this time, a confused resident wandered toward the nurses’ station and another RN, not assigned to the cart, redirected the resident and commented that she would not leave the cart unsecured. The assigned RN later acknowledged the cart should not have been left unlocked, and facility policy and the DON’s statements confirmed that carts must remain locked when unattended and within the nurse’s eyesight when unlocked.
A resident with moderate cognitive impairment reported that meals delivered by room tray were often very cold and that staff did not return to reheat the food as requested. During observation of a lunch meal service, surveyors used a plated room tray as a test tray and found that the hot food items (pulled pork, french fries, and green beans) were all below the facility’s required hot-holding and service temperatures. Dietary staff stated that hot foods should be delivered at or above 135°F and acknowledged that the test tray items were under temperature, despite a written policy requiring hot foods to be at least 135°F at the time of service and room trays to be delivered within a specified time frame.
Surveyors observed a deficiency in food handling when an assistant dietary manager removed covered chocolate cake from refrigeration, then stacked multiple uncovered bowls of cake in her hands so that the bottoms of the bowls contacted the exposed food while transporting them for pureeing. The cakes were then pureed and returned to bowls. The assistant dietary manager and the CDM both acknowledged that food should not be stacked in this manner and that the outside of bowls should not contact food, and facility policy required meal preparation and stacking practices that prevent contamination and maintain food safety.
A resident with severe cognitive impairment and dementia, care planned as high risk for falls, experienced an unwitnessed fall, after which one LPN documented the assessment, neuro checks, and injury care even though another LPN actually responded, assessed the resident, and assisted with returning the resident to bed; interviews confirmed the documenting nurse neither witnessed nor assessed the resident, and the DON noted that some neuro findings charted were inconsistent with the resident being documented as asleep and that assessments must be documented by the nurse who performed them. In a separate issue, an RN was observed leaving an unlocked laptop and face-up paper notes with resident information on a med cart while entering residents’ rooms, contrary to facility HIPAA/privacy policy and leadership expectations that active records not be left unattended or viewable by unauthorized individuals.
A resident with an indwelling urinary catheter, functional quadriplegia, and multiple serious medical conditions had a care plan directing staff to position the catheter bag and tubing below bladder level and away from the room entrance while monitoring for infection. During a surveyor observation with the DON present, the catheter bag was found hanging from a garbage can next to the resident’s recliner without a cover or dignity bag, and the DON acknowledged this placement as an infection control issue.
Surveyors identified that staff failed to maintain dignity and privacy for two residents. One resident with severe cognitive impairment and significant ADL dependence was repeatedly observed with food left on her face after meals and with her gown positioned so that her shoulder, collar-bone, and neck were exposed in public areas during dining and group activities, despite staff acknowledging these situations as dignity concerns. In a separate incident, a resident with moderate cognitive impairment reported being upset after learning that the DON had secretly audio-recorded an in-room interaction about alleged cameras, and staff confirmed the DON used her personal phone to record the entire encounter without informing or obtaining consent from the resident, contrary to facility abuse-prevention and HIPAA/privacy policies regarding recordings and PHI.
A resident with moderate cognitive impairment reported that evening meals were frequently served on Styrofoam plates and bowls, which she disliked, while other staff confirmed hearing resident complaints about meals served on Styrofoam. An evening cook admitted to routinely using Styrofoam for room trays and an assisted dining room without any valid reason such as dish machine malfunction, despite prior instruction from the CDM that meals must be served on regular plates. Facility policies specified that reusable dishware must be used for routine meal service and that disposable dishware was only allowed under limited conditions (e.g., infection control, emergencies, special events, or individualized care plan needs), making the ongoing use of Styrofoam for regular meal service a violation of resident dignity and established policy.
Two residents did not receive care consistent with professional standards and facility policy. One resident with cognitive impairment and a history of multiple falls experienced several unwitnessed falls, yet neuro checks were only documented for some events, with no neurological assessments recorded for other unwitnessed falls despite staff expectations that such assessments be completed. Another resident with chronic venous hypertension and a right lower extremity wound related to prior leg trauma and hardware had longstanding wounds, but the EHR contained only sporadic wound measurements and largely lacked detailed, weekly wound assessments, descriptions, and measurements as required by facility policies. Staff interviews confirmed inconsistent understanding and implementation of post-fall neuro assessments and wound assessment protocols, and the DON acknowledged that documentation and assessments were not completed as expected.
The facility failed to provide adequate nursing staff to ensure timely responses to resident call lights, resulting in multiple documented delays well beyond 15 minutes for several residents. A resident with significant physical impairments and another with moderate cognitive impairment experienced repeated prolonged waits for assistance, while a high fall-risk resident with a care plan requiring prompt call light response also had numerous extended response times recorded. Residents reported long waits and concerns about staffing, and CNAs and an RN acknowledged that call lights sometimes ran longer than 15 minutes, despite an expectation communicated by the DON that calls be answered within that timeframe.
The facility failed to report suspected abuse to the State Agency after a resident reported that another resident entered his room, bumped into objects, startled him, and grabbed his shirt, prompting him to grab the other resident’s shirt while the other resident slapped at his hands before leaving. The incident was reported to staff, documented by the administrator and a RA, and nursing staff were notified, with multiple staff later confirming they were told to closely supervise and separate the two residents. Despite this, facility self-report records contained no report to the State Agency, and the administrator acknowledged the event was not reported because there was believed to be no physical contact.
The facility failed to provide timely and accurate Medicare coverage and financial liability notices to two residents when therapy services were ending. In one case, therapy documentation listed specific last treatment and discharge dates, but the NOMNC and SNF‑ABN forms given to the resident contained inconsistent dates and did not specify the charges the resident would incur after Medicare coverage ended. In another case, a resident received the NOMNC on the same day therapy and discharge occurred, rather than in advance. Facility leadership acknowledged that NOMNC and SNF‑ABN forms were not consistently issued as soon as decisions to discontinue therapy services were made, contrary to the facility’s own ABN policy.
A resident with documented bilateral hearing loss, identified as hearing impaired in the baseline care plan and care plan, and with notes showing ongoing efforts to obtain hearing aids and schedule hearing testing, was inaccurately coded on the MDS as having adequate hearing without hearing aids. The MDS Coordinator based the coding solely on her own interactions with the resident and did not review or identify prior documentation of hearing deficits, while a CNA reported needing to speak to the resident in an elevated voice. Facility policy required that MDS items accurately reflect the resident’s status and that encoded data be verified against clinical documentation before transmission.
A resident with severe infection, diabetes, and an open perianal wound had physician orders and a care plan for wet-to-dry dressing changes twice daily, but the TAR showed multiple missing entries for these treatments, and the verbal wound care order was not documented in the progress notes as required. RNs reported that the wound care order initially did not populate to the TAR, one RN provided wound care without entering the order onto the TAR, and the DON confirmed that wound treatments were not documented on several days. Additionally, the MAR showed that the resident received oxycodone/APAP 5-325 mg three times in one day, despite an order for administration twice daily PRN, and both nursing staff and the DON acknowledged that this exceeded the prescribed frequency, contrary to facility policies on medication administration and documentation.
A resident with bilateral hearing loss, severely impaired cognition, and documented hearing deficits reported difficulty obtaining hearing aids, believing insurance would not cover them. The care plan acknowledged hearing impairment, but the MDS inaccurately documented adequate hearing without devices. Appointment notes showed the facility was waiting on an ENT provider and later a mobile hearing service, while a CMA received a list of contracted hearing aid providers and made calls to the insurer, then forgot to follow up when no return call came. The CMA reported no clear process for communicating insurance barriers, and the Asst Admin, DON, and MDS coordinator all stated they were unaware of the ongoing insurance issue until surveyor interviews, resulting in a failure to effectively assist the resident in accessing needed hearing services.
A resident with severe cognitive impairment and a right heel pressure injury did not receive consistent pressure ulcer care and offloading. The care plan referenced a cushion boot and the TAR included nightly Betadine treatment, but documentation of treatments and wound measurements was incomplete and inconsistent across skin assessments, Skin Issues forms, and progress notes. Observations showed the resident repeatedly in a w/c wearing only socks with feet on the footrests, while heel protectors were left on a recliner or not applied in bed, despite a cue card indicating a pressure boot. Staff interviews revealed uncertainty about whether and when to use the heel protector, lack of clear directions in the care plan and wall picture system, and absence of the device on the TAR, contrary to facility policies requiring documented use of pressure-relieving devices and regular wound assessment.
The facility failed to ensure restorative nursing programs to maintain or improve ROM, strength, and mobility were developed and implemented under RN guidance for two residents. One resident with stroke-related ROM limitations had a care plan listing PROM, AROM, splint/brace use, and transfers, but the RNA reported independently creating the program at readmission, defaulting to PROM based on her own judgment, and was unaware of the resident’s expectation for a new leg brace and additional gait work. Another resident with normal cognition and no ROM limitations had a restorative care plan for ambulation, AROM, and ADLs but reported attending restorative nursing only once, despite staff describing multiple prescribed exercises. Interviews showed restorative programs were primarily written and adjusted by RNAs and an LPN MDS coordinator, with informal, non-RN training and no documented active RN oversight, contrary to facility policy requiring restorative programs to be set up based on comprehensive assessment and under appropriate supervision.
A resident with obstructive sleep apnea and moderate cognitive impairment used a CPAP machine that was observed to have visible sediment and discoloration on the device, reservoir, and mask, while the resident reported that staff had never cleaned the equipment since admission. Nursing staff, including RNs and an LPN, stated they believed the resident cleaned the CPAP herself, yet the care plan and TAR contained no documentation assigning this responsibility to the resident or ordering staff to perform the cleaning. The DON confirmed the lack of documentation despite facility policy requiring CPAP equipment to be cleaned, stored, and documented per manufacturer instructions and the Infection Prevention and Control Program.
Surveyors identified that nursing staff did not follow physician orders and facility protocol during medication administration, resulting in a medication error rate above 5 percent. In one case, a resident with moderate cognitive impairment was given multiple morning medications, including a nebulized bronchodilator that was set up but not started by the RN, who then left and documented it as completed; the resident did not complete the treatment, and the medication remained in the nebulizer canister. In another case, a resident with moderate cognitive impairment received multiple medications including a Dulera inhaler ordered with a requirement to rinse the mouth after each use, but the RN did not provide water or a cup for rinsing. These actions conflicted with the facility’s medication administration protocol, which requires adherence to MD orders, prohibits pre-documentation and leaving meds at bedside, and requires staff to ensure medications are taken before leaving the resident.
A resident who required maximum assistance for transfers fell from a mechanical lift, resulting in serious injuries and transfer to the ED. The facility failed to promptly notify the resident's family or POA of the incident and transfer, with notification occurring approximately two hours after the event due to missing contact information on paperwork. Facility policy required immediate notification, but this was not followed.
Two residents with severe cognitive impairment and pressure ulcers did not receive weekly wound assessments as required by facility policy. Documentation showed missed assessments over several weeks, and staff interviews revealed inconsistent practices regarding assessment frequency. The DON confirmed that weekly wound assessments with measurements and descriptions were expected but not consistently completed or documented.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
The facility did not complete or document required background checks, including criminal history and abuse registry checks, before allowing an LPN to begin employment. The administrator could not provide evidence of approval to work, despite facility policy requiring clearance prior to starting work.
Two residents in an LTC facility experienced falls resulting in fractures due to inadequate supervision and alarm system failures. One resident with severe cognitive impairment fell when alarms failed to alert staff, while another with moderate impairment fell due to incomplete care planning and lack of clear staff guidance. The facility's policies did not ensure proper care plan development and alarm checks, contributing to these incidents.
The facility did not post required notifications of State Survey Agencies and advocacy support in an accessible manner for residents. Information was placed above eye level in small print, and some postings were outdated or missing. The Administrator acknowledged the issue and planned to review the postings.
The facility did not make grievance filing information accessible to residents and failed to resolve a grievance for a resident. No information was posted in common areas, and only one incomplete grievance record was found in the Administrator's office. The Administrator admitted the grievance was not followed up, contrary to the facility's policy requiring resolution within 72 hours.
The facility failed to protect resident-identifiable information by leaving a computer monitor on a medication cart unlocked and unattended, displaying an EHR with personal details. This occurred multiple times, with residents, visitors, and staff passing by. A staff member confirmed the need to lock the screen, and the Administrator acknowledged the requirement.
The facility failed to submit accurate PBJ staffing data for Q4 2024, triggering for low weekend staffing and lack of 24-hour licensed nursing coverage. Inaccuracies arose from unsubmitted time sheets for a traveling nurse and incorrect reporting of agency staff hours. The Assistant Administrator and Administrator acknowledged these issues, with the facility's accountant responsible for data submission to CMS.
The facility failed to maintain an effective QAPI program, resulting in repeated deficiencies in areas such as care plans, medication management, and infection control. The Administrator acknowledged these issues, citing staff turnover and reorganization as contributing factors, and admitted that the facility was not fully utilizing QAPI.
The facility failed to establish and implement effective QAPI policies and procedures, lacking processes for data monitoring, adverse event analysis, and corrective action development. The Administrator admitted the absence of ongoing QAPI programs and documentation, with the last PIP related to Enhanced Barrier Precautions in April 2024. The facility did not utilize QAPI to its fullest potential, and the policy was not updated annually.
The facility failed to maintain records of QAPI committee meetings for one of the three quarters reviewed and did not ensure required attendees, such as the Infection Preventionist and Medical Director, were present. The Administrator acknowledged discrepancies in documentation and stated the facility did not utilize QAPI to its full potential.
A resident with acute respiratory issues reported that the call light system in the facility was not functioning properly, a problem confirmed by staff. The system has been unreliable since December, with failures more common in the south wing. Despite having backup bells, they have not been distributed to residents, leading to complaints about delayed response times.
The facility failed to provide mandatory training on abuse, neglect, and exploitation reporting for its staff, as required by policy. Documentation for the completion of Dependent Adult Abuse/Mandatory Reporter training was missing for two CNAs. The Assistant Administrator acknowledged the oversight, and the Administrator confirmed the expectation for training completion within six months of employment.
The facility failed to provide the required 12 hours of annual in-service training for CNAs, including essential topics like resident rights, dementia care, infection control, and behavioral health. A CNA confirmed the lack of regular training, and both the DON and Administrator acknowledged the deficiency.
The facility failed to document advance directives correctly for three residents, including a resident with hospice services and two residents with moderate cognitive impairment. Their DNR orders were not signed by a physician, contrary to facility policy.
The facility failed to ensure a nurse aide, employed for over four months, completed a state-approved training and competency evaluation program. Despite being hired as a CNA, Staff I's certification was not verified, and she worked on the floor without the necessary credentials. The oversight was identified through employee file reviews and staff interviews, revealing a lapse in following the facility's policy for verifying CNA certification.
The facility failed to identify target behaviors for psychotropic medication use for several residents, leading to deficiencies in medication management. Residents with cognitive impairments were prescribed psychotropic medications without specified target behaviors, and care plans lacked appropriate interventions. The facility did not have a policy for identifying target behaviors, resulting in inadequate monitoring and intervention for residents' behavioral symptoms.
The facility failed to implement its abuse and neglect policy by not completing background checks before hiring a CNA and not providing annual abuse prevention training. An LPN was involved in an incident of forced medication administration without receiving disciplinary action or additional training. The facility's policy requires annual training, which was not documented for the LPN.
The facility failed to adhere to professional standards for food storage, resulting in expired and improperly stored food items in both the dry storage room and walk-in freezer. Items such as pretzels, gravy mix, and soups were found with expired dates, while others like saltine crackers and cereal lacked receiving or expiration dates. The Certified Dietary Manager acknowledged the oversight, and the Administrator noted the need for more frequent checks to prevent serving expired food.
The facility failed to develop comprehensive care plans for several residents, omitting necessary goals, outcomes, and interventions for treatments such as psychotropic and opioid medications, urostomy care, and antiplatelet therapy. Staff acknowledged these omissions, and the facility's policy did not ensure that care plans were directly related to identified focus areas.
The facility failed to update care plans for three residents, leading to deficiencies in reflecting their current conditions and necessary interventions. A resident's care plan was not updated to include hospice care, another resident's care plan lacked documentation of wound care orders and scooter safety interventions, and a third resident's care plan did not include instructions for alarm or call light system failures. The facility's policy did not include procedures for updating care plans, contributing to the oversight.
A facility failed to enter and follow a physician's order for a resident with severe cognitive impairment to wear a mitt/glove on the right hand daily. The order was not entered into the EHR, and the mitt was only applied once, despite the resident's mother providing the mitts. The DON acknowledged the oversight and noted that assessments were not completed as required.
A facility failed to assess and document the use of a restraint for a resident with severe cognitive impairment. Despite a physician's order for a mitt/glove to prevent the resident from pulling out a gastrostomy tube, the necessary restraint assessment was not completed, and the order was not entered into the EHR. The DON and LPN acknowledged the oversight, and the facility did not conduct an evaluation by an occupational therapist as required by protocol.
A facility failed to investigate and report an alleged abuse incident involving a resident with severe cognitive decline. An LPN was accused of holding the resident's hands and forcing medication. The investigation was incomplete, and the LPN returned to work without completing mandatory training. The facility did not maintain required separation between the LPN and the resident, and the investigation results were not properly documented or reported.
The facility failed to ensure proper labeling of medications, leading to discrepancies between medication labels and the MAR. An RN administered insulin without verifying the label, and an LPN received a verbal order for a change in MS Contin dosage without proper documentation. The DON confirmed the lack of stickers for indicating changes and no policy for handling label changes, resulting in potential medication errors.
The facility failed to provide timely notification of financial responsibility when Medicare Part A services were discontinued for two residents with severe cognitive impairments. The facility did not issue the required Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) forms in advance, and the documentation was incomplete or delayed. The Assistant Administrator acknowledged issues with the notification process, and the facility lacked a policy for Advanced Beneficiary Notices.
A facility failed to accurately assess a resident's medication use on the MDS, incorrectly documenting insulin therapy instead of the prescribed Ozempic. This coding error was acknowledged by both the LPN/MDS Coordinator and the DON, highlighting a failure to adhere to the facility's policy for accurate data collection.
A facility failed to complete a PASRR for a resident diagnosed with new mental disorders, including Anxiety Disorder, Depression, Psychotic Disorder, and PTSD. Despite being on multiple medications for depressive disorder, the PASRR Level I Screen Outcome did not indicate a need for intervention. The DON acknowledged the oversight, and the Administrator recognized the need for a process to ensure PASRR completion with new diagnoses.
A resident with severe cognitive decline and multiple health issues was not treated with dignity during medication administration. An LPN held the resident's hands to prevent arm flinging and forced medications, despite the resident's history of refusing them. The facility's policy lacked guidance on handling medication refusals, and the DON expected documentation of such refusals.
A resident with moderate cognitive impairment was left in an unsanitary environment due to a commode not being emptied for at least 8 hours. The toilet in the resident's room was taped shut due to previous plumbing issues caused by flushing inappropriate items. Staff interviews revealed a lack of training and awareness regarding the maintenance of the commode, leading to a strong odor of urine and feces in the room. The facility's administration acknowledged the need for regular checks and emptying of the commode, but these expectations were not effectively communicated to the staff.
A resident with multiple health issues, including severe cognitive impairment, refused scheduled nebulizer treatments for several days. Despite this, the facility did not notify the PCP, as their policy required notification only for significant changes. The DON noted the resident's history of treatment refusal, while the PCP stated that being informed would have been beneficial.
Unsecured Medication Cart Left Unlocked and Out of Sight
Penalty
Summary
Facility staff failed to secure prescribed medications from possible unauthorized access when a medication cart was left unlocked and unattended in the nurses’ station area facing the lobby. During observation, an RN assigned to the cart was positioned on the opposite side of the lobby, facing a resident and with her back partially turned toward the cart, and a vase of flowers blocked her line of sight to the cart. The unlocked cart contained gabapentin, escitalopram, and multiple blood pressure medications. While the cart was unsecured, a confused resident was observed wandering toward the nurses’ station, and another RN, who was not assigned to the cart, redirected the resident and verbally acknowledged she would not leave the cart unsecured. The assigned RN later stated that medication carts are not typically left unlocked when staff walk away and admitted the cart should not have been left unlocked, explaining she had gone to give medications to a resident who was yelling that her taxi was waiting for an appointment. The DON stated that staff are expected to lock the cart if they are going to leave it unattended. A facility document titled “Protocol for Medication Administration” indicated that medication carts must be in the possession of the nurse or medication aide at all times and, when unlocked, must remain within eyesight of the nurse or medication aide at all times. These observations and statements showed that the cart was not kept within the nurse’s line of sight and was left unlocked contrary to facility protocol, resulting in unsecured medications accessible in a public area while a confused resident was nearby.
Failure to Provide Hot Food at Required Temperatures for Room Tray Service
Penalty
Summary
The deficiency involves the facility’s failure to provide hot food at an appetizing and policy-compliant temperature to a resident receiving room tray service. Resident #24, who had a BIMS score of 12 indicating moderate cognitive impairment, reported that her food was served very cold most of the time and that when she asked staff to reheat the food, they said they would but did not return. Staff interviews confirmed that this resident had complained about cold food and not getting enough food, and that these concerns had been reported to the Certified Dietary Manager. Surveyors observed the lunch meal tray plating and delivery process and conducted a test tray temperature check. The second plated room tray was used as a test tray and remained on the delivery cart while other trays were delivered. When the test tray was checked, the temperatures of the hot food items were below the facility’s required standards: pulled pork measured 114°F, french fries 105°F, and green beans 108°F. Dietary staff, including the Assistant Dietary Manager and the Certified Dietary Manager, acknowledged that hot foods should be delivered to residents at or above 135°F and that food must remain out of the danger zone. The facility’s written policy required hot foods to be at least 135°F when served and room trays to be delivered within 5 minutes of plating, with temperatures rechecked if delivery exceeded that time, but the observed practice did not meet these standards for at least one resident.
Improper Stacking and Handling of Uncovered Food During Meal Preparation
Penalty
Summary
Surveyors identified a deficiency in food handling practices when staff failed to transport and handle food in accordance with professional standards and facility policy. During observation, an assistant dietary manager retrieved chocolate gooey cake from the walk-in refrigerator where it was stored in styrofoam bowls covered with clear plastic wrap on trays. The staff member then removed the bowls from the trays and stacked two uncovered cakes in one hand and three uncovered cakes in the other, with the bottoms of the bowls directly contacting the exposed food surfaces as they were carried to the preparation table. The cakes were then processed to the appropriate pureed consistency and returned to styrofoam bowls using an appropriate scoop. The assistant dietary manager later acknowledged that the cakes should not have been stacked without a protective cover between each bowl and that the outside of the bowls should not have come into contact with the food. The certified dietary manager confirmed that food should not be stacked in this manner and that, if stacking occurs, the food should be covered with a lid or plastic wrap to prevent contamination. Review of the facility’s undated “Meal Preparation” policy showed it required food to be prepared, handled, and stacked in a manner that maintains food safety, prevents contamination, and complies with Iowa Food and Drug Code requirements, including that stacking must not compromise hygiene. The observed practice of stacking uncovered bowls of cake during preparation did not comply with these standards.
Inaccurate Fall Documentation and Unsecured PHI During Medication Pass
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a cognitively impaired resident and to ensure that documentation was performed by the nurse who actually conducted the assessment. Resident #4 had severe cognitive impairment with diagnoses of Alzheimer’s disease, non-Alzheimer’s dementia, and depression, and was care planned as high risk for falls with interventions including a bed in the lowest position, bed/chair alarm, and a fall mat. A progress note and unwitnessed fall form, both attributed to Staff V (LPN), documented that the resident was found on the floor by the bed, assessed for vital signs and range of motion, had an abrasion to the mid-left back cleansed, was lifted back to bed with a mechanical lift, and had neuro checks initiated. The neurological flow sheet entries under Staff V’s name further documented detailed neuro assessments, including pupil size/reaction, hand grasps, and speech, at multiple time points. Interviews later revealed that Staff V did not respond to the initial call for assistance, did not witness the fall, and did not assess Resident #4 at the time of the incident. Staff V stated that Staff W (LPN) had already completed the assessment and returned the resident to bed before she arrived, and that she documented based on Staff W’s report. Staff W confirmed she was the nurse who responded to the CNA’s call, found the resident seated on the floor mat with her back against the bed, completed range of motion and pain assessments with no abnormal findings, and assisted with two CNAs to return the resident to bed. Staff W acknowledged she had Staff V complete the fall and assessment documentation and could not justify why. CNA Staff S reported hearing the bed alarm and the resident calling for help, finding the resident on the floor mat with the bed higher than previously placed, and observing Staff W perform assessments and vital signs, while confirming that Staff V did not assess the resident at the time of the fall. The DON later stated that if the resident was documented as sleeping, staff should not have documented hand grasps and pupil assessments, and that documentation must be completed by the nurse who performed the assessment. A separate deficiency was identified regarding failure to maintain confidentiality of residents’ records during medication administration. During continuous observation of Staff A (RN) administering medications, the nurse was seen entering residents’ rooms while leaving the laptop computer on the medication cart open and unlocked, with the screen visible, and paper notes containing documentation left face up and readable on the cart. This occurred on more than one occasion while the nurse was away from the cart. The Administrator and DON acknowledged that computers were not to be left open and that documentation papers were not to be left uncovered and viewable by others. The facility’s HIPAA/Privacy Safeguarding and Storing Protected Health Information policy stated that active medical records should not be left unattended in areas where residents, visitors, and unauthorized individuals could easily view them.
Improper Positioning of Indwelling Catheter Bag on Garbage Can
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to the care of a resident with an indwelling urinary catheter. The resident’s MDS documented a BIMS score of 15, indicating no cognitive impairment, and diagnoses including acute and chronic respiratory failure with hypoxia, unspecified nondisplaced fracture of the seventh cervical vertebra, unspecified fracture of the first thoracic vertebra, functional quadriplegia, and a need for assistance with personal care. The MDS and care plan documented the presence of an indwelling catheter for obstructive uropathy, with interventions directing staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door, and to monitor for symptoms of infection. During an observation in the resident’s room with the DON present, the resident’s catheter bag was seen hanging from a garbage can next to the resident’s recliner without a cover or dignity bag. At the time of the observation, the DON stated that placing the catheter bag on the garbage can was an infection control issue and that she would expect the catheter bag to be hung somewhere else that was not the side of the garbage can.
Failure to Maintain Resident Dignity and Privacy During Care and Unauthorized Recording
Penalty
Summary
The deficiency involves failures to honor residents' rights to dignity, respect, and privacy. For one resident with severely impaired cognition, a history of stroke with right-sided weakness, non-Alzheimer's dementia, and seizure disorder, surveyors observed that after lunch the CNA transported the resident to her room and positioned her in a wheelchair facing the open doorway with mashed potatoes left below her left lower lip. Over 30 minutes later, the resident remained in the same position with food still on her face, despite her care plan indicating she required assistance with eating on days she was more tired and that staff were to perform oral hygiene. Staff later acknowledged that leaving food on a resident's face when they are put in their room is a dignity concern. On a separate occasion, the same resident was observed in a dining conference room with her gown positioned so that her right shoulder, collar-bone, and the nape of her neck were fully exposed while being assisted with eating. After being transported back to her room, the CNA briefly pulled the gown over the resident's right shoulder and left, but the gown slipped back down, again exposing the same areas. Later that morning, the resident was transported to the lobby for a group activity with her gown still positioned below her right shoulder, exposing her shoulder, collar-bone, and neck in a public area with other residents present. Multiple staff members stated that leaving food on a resident's face and having a female resident's shoulder, collar-bone, and neck exposed in a public setting are dignity concerns, and the DON stated staff should have assisted the resident to clean her face and readjust her clothing. A separate deficiency involved the DON recording another resident without the resident's knowledge or consent. This resident, who had moderate cognitive impairment per the MDS, reported that the DON and the MDS coordinator came into her room and argued with her about alleged cameras in the room, accusing her of recording staff. The resident stated that a police officer later told her the DON had recorded their interaction, and she felt that being recorded without her knowledge was very upsetting and disrespectful. Staff interviews confirmed that the DON entered the room with the MDS coordinator and recorded the entire encounter using her personal phone, which she placed in her pocket, without informing or asking permission from the resident. The DON acknowledged there was no facility policy for staff recording residents and that she saw a dignity issue with recording the resident without her knowledge, despite existing facility policies prohibiting staff from taking or using photographs or recordings in a manner that would demean or humiliate residents and requiring protection of PHI under HIPAA/privacy safeguards.
Inappropriate Use of Styrofoam Dishware for Resident Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide a homelike environment and maintain resident dignity by routinely serving meals on Styrofoam plates and bowls without an appropriate reason. A resident with a BIMS score of 12, indicating moderate cognitive impairment, reported that evening staff served most meals on Styrofoam and that she disliked this practice and did not know why actual plates were not used. Staff interviews revealed that one evening cook regularly used Styrofoam for room trays and an assisted dining room, despite there being no dish machine malfunction or other valid reason. This cook acknowledged there was no real reason for using Styrofoam and admitted to having been previously instructed that meals were supposed to be served on regular plates and bowls. Additional staff confirmed that residents had complained about meals being served on Styrofoam and identified the same evening cook as the one using disposable dishware. The Certified Dietary Manager stated that she had previously held a sit-down discussion with this cook about the inappropriate use of Styrofoam and that he had acknowledged understanding not to use it for routine meal service, yet he admitted to continued use. Review of the facility’s Disposable Dishware Use Policy and Meal Delivery / Room Trays policy showed that reusable dishware was required for routine meal service, and that disposable dishware was only permitted under specific conditions such as infection control needs, emergency situations, special events, or individualized care plan needs. The continued use of Styrofoam for regular meal service, including room trays, occurred outside of these policy-defined circumstances and was identified by the CDM as a dignity issue.
Failure to Complete Post-Fall Neuro Checks and Ongoing Wound Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents, specifically related to post-fall neurological assessments and wound assessments. For one resident with a history of stroke, psychiatric diagnoses, and multiple prior falls and fractures, the clinical record documented numerous falls, both witnessed and unwitnessed, over several months. The resident’s care plan identified a high risk for falls and included multiple fall-prevention interventions. Progress notes and facility fall documents listed several unwitnessed falls, including events where the resident lowered herself to the floor, fell from a recliner, slid from a wheelchair, or slipped while reaching for a call light. Despite these events, the neurological checklist and assessment records showed that neuro checks were only completed for some of the falls. The same resident’s medical record lacked neurological assessments for several unwitnessed falls on specific dates, even though the facility’s own staff, including the MDS Coordinator/LPN and the DON, stated that their expectation was that neurological assessments be completed after unwitnessed falls. The record showed neuro assessments on certain dates, but for other documented unwitnessed falls, only 15‑minute checks or no neuro assessments at all were recorded. Physician notifications were documented for some falls, and an emergency room report following one fall indicated no acute injuries, but the absence of consistent neurological assessments after unwitnessed falls represented a failure to follow the facility’s stated expectations and professional standards for post-fall evaluation. The second resident had chronic venous hypertension with ulcer and inflammation of the right lower extremity and a history of significant leg trauma with hardware in place. Facility documents showed that the resident had been referred to a wound care clinic, with physician orders noting that the right lower extremity wound probed down to hardware and that there was a chronic implant-related infection. Observations revealed multiple small scabbed areas on the inner right lower extremity. Review of the EHR showed that, over the prior year, there were no consistent wound assessments with measurements or detailed descriptions in the wound assessment section, and only a few progress notes contained wound measurements on scattered dates. Other progress notes documented only monthly skin assessments without wound descriptions or measurements. Nursing staff interviews confirmed inconsistent understanding and implementation of wound assessment practices. One RN who frequently performed the resident’s wound care stated she did not know when skin assessments were supposed to be completed and reported that the wound had not worsened, indicating she would have notified the DON and physician if it had. Another LPN stated that skin assessments were supposed to be completed weekly with measurements and descriptions and reported entering measurements during a treatment. The DON acknowledged that there were not as many wound assessments in the progress notes as expected and that assessments were not completed appropriately by nursing staff. The PCP reported he had not recently examined the wound and had no notes from the wound clinic, and stated he would expect the facility to notify the wound clinic of any changes. Review of facility policies on documentation and wound assessments showed requirements for detailed wound descriptions, weekly measurements, and thorough documentation of treatment and wound appearance, which were not consistently followed for this resident’s chronic wound. Facility policies titled “Protocol for Documentation” and “Protocol for Wound Assessments” required that wound care notes include treatment provided, detailed appearance of the wound, new concerns, physician notification for ongoing treatment, EHR updates to reflect current treatment, and weekly measurements documented in the EHR. The review of the resident’s records demonstrated that these requirements were not met, as there were gaps in wound assessments, lack of consistent measurements, and insufficient descriptive documentation over many months. Together with the missing neurological assessments after multiple unwitnessed falls for the other resident, these findings show that the facility failed to provide needed services and assessments in accordance with professional standards and its own policies for both post-fall care and wound management.
Delayed Call Light Responses Due to Insufficient Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to respond to resident call lights in a timely manner, resulting in repeated delays in answering calls for assistance. One resident with no cognitive impairment and multiple serious diagnoses, including acute and chronic respiratory failure with hypoxia, vertebral fractures, and functional quadriplegia, reported that on the evening and overnight shifts it often took much longer than 15 minutes for staff to respond to call lights, and that on the overnight shift it had taken over an hour on at least one occasion. Call light system reports for this resident’s room over several days documented multiple instances where call lights remained unanswered for between approximately 19 and 50 minutes. Another resident with moderate cognitive impairment also had multiple call light activations recorded as unanswered for more than 15 minutes, ranging from about 18 to 49 minutes. A third resident, with moderate cognitive impairment and a history of stroke, multiple psychiatric diagnoses, and multiple falls and a fracture related to falls prior to admission, had a care plan identifying high fall risk with interventions including keeping the call light within reach and prompt response to all requests for assistance. However, call light reports for this resident showed numerous delays between approximately 16 and 47 minutes. This resident stated she felt there was not enough staff because she had to wait a long time for call lights at times. CNAs and an RN acknowledged that call lights sometimes took longer than 15 minutes to answer, and the DON stated the expectation was that call lights be answered in under 15 minutes, while the written call light policy did not specify a response time.
Failure to Report Suspected Resident-to-Resident Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report suspected abuse between two residents to the State Agency after being made aware of the incident. A grievance form documented that one resident reported another resident entering his room, bumping into objects, and startling him, causing him to spill his coffee. The reporting resident stated he tried to stop the other resident by grabbing his merry walker to prevent a fall due to spilled coffee. He reported that the other resident then grabbed his shirt, and he responded by grabbing the other resident’s shirt; the other resident then let go and slapped at his hands before leaving the room. The resident also reported feeling upset and threatened because he was not able to stand or defend himself. An incident document completed by the administrator recorded a similar account, including that the resident felt startled and that the other resident grabbed his shirt, with the reporting resident grabbing the other resident’s shirt tail and the other resident swatting at his hands with no contact. A restorative program note showed that the resident stopped a staff restorative aide in the hallway to report the incident, and that the nurse was notified immediately. Staff interviews confirmed that the incident was reported up the chain of command and that staff were instructed to provide closer supervision and keep the two residents apart. However, review of the facility’s self-report documents showed no incident reported to the State Agency within 48 hours of the event, and the administrator stated the interaction was not reported because there was no physical contact, resulting in a failure to report suspected abuse as required.
Failure to Provide Timely and Accurate Medicare Coverage and Liability Notices for Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide required Medicare notices regarding the end of coverage and potential financial liability for therapy services. For one resident, a therapy discharge notification dated 8/31/25 indicated the last treatment date would be 9/4/25 with a discharge date of 9/5/25. That resident signed a Notice of Medicare Non-Coverage (NOMNC), CMS Form 10123, on 9/2/25 stating coverage of therapy services would end on 9/5/25, and then signed a Skilled Nursing Facility Advanced Beneficiary Notice (SNF‑ABN), CMS Form 10055, on 9/5/25 indicating the resident would begin incurring costs for therapy on 9/6/25 if choosing to continue services. The facility did not provide the resident with documentation of the specific charges that would occur prior to the last date of covered services and did not maintain consistent dates between the therapy department’s discharge notification and the coverage/discharge dates reflected on the notices. For another resident, a therapy discharge notification dated 1/13/26 indicated the last treatment date and discharge date would both be 1/20/26, with discharge planned because all goals were met and the resident was returning home at prior level of function. This resident signed the NOMNC on 1/20/26, meaning the facility did not provide notification of the ending of Medicare-covered services prior to the discharge date. Interviews with the Assistant Administrator/Billing Manager and the Administrator confirmed that documents related to NOMNC and SNF‑ABN were not consistently provided as soon as notification for discontinuation of therapy services was made, despite the facility’s ABN policy requiring that a SNF‑ABN be issued before providing services that may not be covered and before reducing services that the facility believes Medicare will not pay for, allowing time for the beneficiary to sign and ask questions.
Inaccurate MDS Coding of Resident Hearing Status
Penalty
Summary
Failure to complete an accurate comprehensive assessment occurred when the facility did not correctly code a resident’s hearing status on the MDS. The resident reported being hard of hearing and stated she had been trying to obtain hearing aids, but her insurance would not cover them. The baseline care plan identified the resident as hearing impaired, and the comprehensive care plan included a hearing deficit focus with interventions such as validating the resident’s message by repeating it aloud. Appointment notes documented ongoing efforts to coordinate with an ENT provider and a mobile hearing service regarding hearing aids and hearing testing. The resident’s diagnoses included bilateral hearing loss. Despite this information, the MDS assessment documented that the resident had adequate hearing without hearing aids or other hearing appliances. The MDS Coordinator stated she coded the resident as having adequate hearing because, during her own interactions, the resident did not report difficulty hearing and appeared to respond as though she could hear. She also stated that her assessments were based solely on her own interactions with residents unless something was noted in the progress notes, and she did not identify the prior documentation of the resident’s hearing deficit. A CNA reported needing to speak to the resident with an elevated voice because the resident did not seem to hear well. The DON stated the MDS should be accurate and follow the diagnoses, and facility policy required that every MDS item accurately reflect the resident’s status during the look-back period and that the RN Coordinator verify encoded data against clinical documentation before transmission.
Failure to Follow and Document Wound Care and PRN Pain Medication Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide and document wound care and pain medication in accordance with physician orders and professional standards for one resident. The resident had normal cognition and diagnoses including severe life-threatening blood infection, diabetes, and a rare flesh-eating bacterial infection, with an open lesion requiring wound management. A verbal order was obtained for wet-to-dry dressing changes twice daily to the perianal wound, with packing and appropriate dressings, and this order was signed and entered into the physician orders. The resident’s care plan included wound management interventions such as regular wound measurements, monitoring for infection, and wet-to-dry dressing changes twice daily. However, the progress notes did not contain the verbal order received earlier in the day, and the Treatment Administration Record showed multiple missing entries for the ordered wound treatments on several days, despite staff and the DON acknowledging that at least some treatments were performed. The Medication Administration Record showed an order for oxycodone/APAP 5-325 mg, one tablet twice daily as needed, but the resident received three doses in a single day, exceeding the ordered frequency. Staff interviews revealed that RNs were aware of issues with orders not populating to the TAR and that one RN knew wound treatment orders were missing from the TAR but did not enter them, even though she provided a wet-to-dry dressing based on verbal instruction. Another RN stated she entered the dressing change order but it did not populate to the TAR until she later corrected it. The DON and Administrator both acknowledged that wound treatments were not documented on the TAR for specified days and that the resident should not have received three doses of oxycodone when ordered for two. Facility policies on medication administration and documentation required that medications be administered per physician orders and that all new orders, including wound care, be documented in the nurse’s notes with details of the treatment and wound appearance, which did not occur in this case.
Failure to Assist Resident in Obtaining Hearing Aids and Coordinate Insurance Barriers
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to assist a resident in obtaining needed hearing devices through available resources. The resident reported being hard of hearing and stated she had been trying to get hearing aids but her insurance would not cover them. Her care plan included a hearing deficit focus with an intervention for staff to validate her messages by repeating them aloud. The MDS assessment documented a BIMS score of 7/15 indicating severely impaired cognition, diagnoses including heart failure, depression, and bilateral hearing loss, and noted she required supervision with several ADLs while being independent with others. Despite this, the MDS documented she had adequate hearing without hearing aids or other appliances, and staff CNAs reported needing to speak to her in an elevated voice because they did not think she could hear well. Appointment notes showed that on one occasion the facility was waiting for the ENT provider to supply a phone number for the insurance company regarding hearing aids, and later was waiting for a response from a mobile hearing service to schedule a hearing test. A CMA reported that the ENT provider had given a list of hearing aid providers contracted with the resident’s insurance and that she made multiple attempts to contact the insurance provider, was told she would receive a call back, and then forgot about the issue when no call was returned. She also stated she did not know of any official process for communicating insurance barrier situations and usually spoke with the DON or MDS coordinator when expecting return calls. The assistant administrator, DON, and MDS coordinator all stated they were unaware of the ongoing hearing aid insurance barrier or process delay until the day of the survey interviews, and the DON later stated staff should have notified her or the MDS coordinator of the ongoing communication attempts, demonstrating a lack of effective follow-through and communication in assisting the resident to obtain hearing devices.
Failure to Consistently Offload and Monitor Right Heel Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent further wound development for a cognitively impaired resident with an existing right heel pressure injury. The resident had severe cognitive impairment with a BIMS score of 4/15 and diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, and depression. Clinical documentation showed a history of a deep tissue injury and then an unstageable pressure ulcer on the right lateral heel, with multiple measurements recorded over several months. The care plan identified a focus on potential/actual impairment to skin integrity and referenced assistance with protective garments such as a cushion boot, and the TAR included an order for nightly Betadine treatment to the right lateral heel. However, there was at least one missed documentation entry for the ordered treatment, and wound measurements and descriptions were inconsistently documented across Skin Issues forms, Skin and Wound assessments, and progress notes. Over time, the wound was variously described as a deep tissue injury, a Kennedy terminal ulcer/end-of-life pressure area, and an in-house acquired unstageable pressure ulcer, with differing measurements and incomplete data. For example, a Skin Issues entry on one date documented the right heel as an in-house acquired, chronic, unstageable pressure area measuring 0.75 cm by 1.16 cm with no depth, while a later Skin Issues entry documented a new right heel pressure ulcer/injury, also in-house acquired and chronic, measuring 1.5 cm by 3.5 cm with no depth and no area calculation. Several Total Body Skin assessments identified a new wound or did not identify a pressure ulcer at all and did not provide measurements. Progress notes over several months recorded varying sizes and descriptions of the right heel wound, including dark black/brown hard tissue and later a light brown scabbed area, but the documentation did not consistently align with the facility’s own protocols for weekly skin assessments with measurements and descriptive wound notes for daily dressing changes. The facility also failed to consistently implement and monitor offloading interventions, specifically the use of a heel protector/boot to relieve pressure on the resident’s right heel. Observations on multiple days showed the resident seated in a wheelchair wearing only socks, with her feet on the footrests, while foam heel protectors or a blue foam bootie were seen on the recliner rather than on the resident. The resident was also observed in bed without a heel protector after personal care, despite a picture cue card above the bed indicating a pressure boot for the right foot. Interviews with CNAs, an RN, and the DON revealed uncertainty about whether the resident still required a heel protector, when it should be used (in bed vs. in the wheelchair), and whether there were physician orders or TAR entries for the device. Staff reported relying on a picture system on the wall to know if a resident needed a heel protector, but the DON acknowledged that the care plan and picture system did not specify when the boot should be worn and that the boot was not placed on the TAR, making it difficult to monitor its use. These actions and omissions conflicted with the facility’s policies requiring documentation of assessments, interventions, and use of pressure-relieving devices to prevent further skin breakdown.
Failure to Provide RN-Guided Restorative Nursing to Maintain ROM and Mobility
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement restorative nursing programs to maintain or improve residents’ range of motion (ROM), strength, and mobility under the direct guidance of an RN, as required by facility policy and based on comprehensive assessments. For one resident with a history of stroke and multiple psychiatric diagnoses, the admission MDS documented functional limitations in both upper and lower extremities and receipt of PROM, AROM, splint/brace assistance, bed mobility, transfers, and dressing/grooming. The resident’s care plan included a restorative focus with specific interventions such as resistive exercises, bed mobility, PROM, splint/brace use, and transfers, initiated by the DON/RN and later revised by a Restorative Nursing Assistant (RNA). The resident reported wanting to walk more and expecting a new leg brace and work on uneven bars, but staff were unaware of a new brace, and the RNA described creating the restorative program at readmission and defaulting to PROM when no AROM was present, using her own judgment on how far to stretch until resistance was felt. For a second resident with normal cognition and diagnoses including severe blood infection, diabetes, and a rare flesh-eating bacterial infection, the MDS showed independence with dressing, toileting, bed mobility, and transfers, and supervision for ambulation without ROM limitations. The MDS also documented receipt of AROM, bed mobility, transfers, and dressing/grooming over the look-back period. The care plan contained a restorative focus with interventions for ambulation, AROM, bed mobility, dressing/grooming, and transfers, as well as a self-care performance deficit focus emphasizing independence with basic ADLs. However, the resident stated he had only attended restorative nursing once since admission, despite having exercise equipment in his room and additional resistance bands provided by staff. The RNA reported that this resident used overhead pulleys, bicep curls with and without light weights, and AROM for lower extremities, and that the restorative program had been written on the care plan by another staff member. Interviews with staff and review of facility practices showed that restorative programs were being developed and modified primarily by RNAs and an MDS Coordinator who was an LPN, rather than under the direct guidance of an RN as required by the facility’s restorative policy. The DON explained that RNAs write programs, take them to the MDS Coordinator, and then to the DON, and that RNAs can write programs and place them directly into care plans, with feedback largely coming from RNAs and residents. The DON acknowledged there was no documentation showing her active involvement in program development, that she only reviewed care plans quarterly, that RNAs should not be assessing residents for program development and changes, and that she was unaware of the training RNAs had for restorative work. Additional interviews revealed that staff responsible for restorative programming were trained informally by other non-RN staff, with one staff member self-taught through books and internet searches and without formal restorative training, contrary to the facility’s policy that programs be set up by restorative supervision and the MDS/Care Plan Coordinator and based on comprehensive assessment.
Failure to Ensure Proper Cleaning and Documentation of CPAP Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory services in accordance with professional standards of practice for a resident who required use of a CPAP machine for obstructive sleep apnea. The resident’s MDS documented moderate cognitive impairment with a BIMS score of 12 and a diagnosis of obstructive sleep apnea. The resident reported that no facility staff had ever cleaned her CPAP machine or mask since admission. Observation of the CPAP equipment showed speckled white sediment on the outside of the machine, discolored water in the reservoir, and cloudy white sediment and film on the inside of the mask, along with dry red material on areas of the mask. Review of the resident’s care plan revealed no documentation that the resident was responsible for cleaning her own CPAP machine or mask. The TAR contained no orders for staff to clean the CPAP machine or mask. Multiple nursing staff, including RNs and an LPN, stated they had never cleaned the resident’s CPAP equipment and believed the resident cleaned it herself, while also acknowledging that such responsibility should have been documented in the care plan and/or TAR if the resident were to perform this task. The DON stated the resident had told her she would clean her own CPAP and did not need staff help, but acknowledged that the care plan and TAR did not reflect this. Facility policy on CPAP and nebulizer cleaning required equipment to be cleaned and disinfected according to manufacturer instructions and maintained and documented per CMS and the facility’s Infection Prevention and Control Program, which was not followed in this case.
Medication Administration Errors and Noncompliance With Physician Orders
Penalty
Summary
The deficiency involves the facility failing to maintain a medication error rate below 5 percent, with surveyors identifying an 8.33 percent error rate during observation. For one resident with moderate cognitive impairment and no care plan focus or interventions for independent medication administration, an RN prepared multiple morning medications, including a nebulized Ipratropium-Albuterol treatment and oral medications such as Milvexian, Levothyroxine, acetaminophen, aspirin, Cymbalta, Levetiracetam, Meloxicam, Pantoprazole, Senna, and Cholecalciferol. The RN poured the nebulizer solution into the canister but did not start the nebulizer, then left the room and documented the treatment as completed in the electronic medical record. Subsequent observations showed the resident briefly turned the nebulizer on and then off, did not resume the treatment, and went to breakfast, leaving the medication still in the nebulizer canister. The DON confirmed the resident did not have an order for self-administration and that staff should not leave medications at the bedside or document administration before ensuring completion. Another resident with moderate cognitive impairment was observed receiving multiple medications, including Omeprazole, aspirin, Dulera inhaler, Fluticasone, Duloxetine, Guaifenesin, PreserVision ARED 2+ Multi Vital, Torsemide, and Cholecalciferol. After administering the medications, nasal spray, and Dulera inhaler, the RN did not provide water or an empty cup for the resident to rinse her mouth, despite a physician’s order specifying that the resident should rinse her mouth after each use of the Dulera inhaler. The facility’s Medication Administration Protocol required that all medications be administered in accordance with physician orders, prohibited documenting medications prior to administration, prohibited leaving medications at the bedside, and required staff to assure medications were taken prior to leaving the resident. The observed practices with both residents were inconsistent with these requirements and contributed to the identified medication error rate above the acceptable threshold.
Failure to Timely Notify Family of Resident's Fall and Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative or family member of a significant change in condition and transfer to the Emergency Department (ED) following a fall from a full body mechanical lift. The resident, who had no cognitive impairment and required maximum assistance for transfers, experienced a fall that resulted in serious injuries, including a neck fracture, thoracic compression fracture, and bleeding around the brain. Although the physician was notified of the fall, staff did not immediately notify the resident's family or Power of Attorney (POA) due to the absence of a phone number on the transfer paperwork. The Director of Nursing (DON) later located the contact information and notified the family, but this occurred approximately two hours after the incident. Interviews with staff and the resident's family confirmed that the family was not informed of the fall or the transfer to the ED until after the DON came on shift and made the call. The family member reported not receiving any missed calls from the facility and only learned of the incident after being prompted by hospital staff. Facility policy required immediate notification of family or POA in the event of emergency incidents, but this expectation was not met in this case, as documentation and staff interviews confirmed the delay in notification.
Failure to Complete Weekly Wound Assessments for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to provide weekly wound assessments for two residents with pressure ulcers, as required by facility policy. For one resident with severe cognitive impairment and an unstageable pressure ulcer on the left heel, documentation showed gaps in weekly wound assessments, with no assessments completed during several multi-week periods. The resident's wound was discovered and documented, but subsequent assessments were not consistently performed or recorded on a weekly basis, as confirmed by both progress notes and hospice wound records. The Director of Nursing (DON) acknowledged that there should have been weekly wound assessments with measurements and descriptions, and that documentation was lacking during the identified periods. A second resident, also with severe cognitive impairment and a deep tissue injury to the right lateral heel, did not have weekly wound assessments documented for a period of time following the discovery of the wound. Staff interviews revealed inconsistent practices regarding the frequency of wound assessments, with some staff indicating that assessments depended on wound severity or dressing changes, rather than adhering to the weekly requirement. Facility policy specified that weekly measurements and assessments should be documented in the electronic health record, but this was not consistently followed for the residents in question.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Complete Required Background Checks Prior to Employment
Penalty
Summary
The facility failed to complete required background checks, including the Iowa Criminal History, Iowa Sex Offender Registry, and Iowa Central Abuse Registry, prior to the employment of an LPN. The personnel file for this staff member showed a hire date and a Single Contact License and Background Check (SING) form indicating that further research was needed due to a record found, but there was no documentation confirming approval to work. The administrator was unable to provide evidence, either printed or electronic, of the approval to work statement, despite acknowledging that such approval was required when further research was indicated. Facility policies stated that background checks must be completed and cleared before an employee starts work, and documentation of these checks must be maintained prior to hire. However, the required documentation was missing from the personnel file, and the administrator confirmed ongoing issues with the process for submitting and tracking background check documentation.
Inadequate Supervision and Alarm Failures Lead to Resident Falls
Penalty
Summary
The facility failed to protect two residents from accidents and injuries due to inadequate supervision and failure to ensure the proper functioning of alarm systems. Resident #33, who had severe cognitive impairment and was at high risk for falls, fell and sustained a right humerus fracture when his alarm failed to alert staff. The care plan for Resident #33 included the use of multiple alarms, but observations revealed inconsistencies in alarm placement and functionality. The facility's documentation lacked evidence of regular checks on the alarms, and staff interviews confirmed that the alarms were not consistently checked every shift as required. Resident #193, with moderate cognitive impairment and a history of falls, fell and sustained a left hip fracture after getting up without assistance. The baseline care plan for Resident #193 was incomplete and did not provide adequate instructions for staff regarding the resident's assistance needs for transfers and mobility. Despite therapy recommendations and discussions to remove alarms due to the resident's agitation, there was no documentation of alternative interventions being implemented. The care plan was not updated to reflect the resident's needs, and staff interviews indicated a lack of clarity regarding the resident's required level of assistance. The facility's policy on care planning did not adequately address the development and updating of care plans, contributing to the deficiencies observed. The lack of proper documentation and adherence to care plan interventions resulted in both residents experiencing falls with significant injuries. The facility's failure to ensure the functionality of alarm systems and provide clear guidance for staff on resident care needs directly contributed to the incidents involving Resident #33 and Resident #193.
Failure to Post Accessible State Agency and Advocacy Information
Penalty
Summary
The facility failed to post required notifications of State Survey Agencies and other advocacy support in a manner that was accessible and understandable to residents or their representatives. Observations made by surveyors during the survey period revealed that information on how to contact state agencies was posted above eye level and in small print, making it difficult for residents to access. Additionally, information on Residents Rights was not posted, and a flyer with outdated contact information was observed. During a facility tour, it was noted that the required postings with names, addresses, and telephone numbers of pertinent State agencies and advocacy groups were not displayed in an easily visible or accessible area, and some postings were outdated. The Administrator acknowledged the issue and stated he would review the area to ensure the information was correct and present.
Failure to Provide Grievance Information and Resolve Complaints
Penalty
Summary
The facility failed to provide residents with accessible information on how to file grievances and did not adequately resolve a grievance for one resident out of eight reviewed. During an observation, it was noted that there was no posted information in the common areas regarding the process for filing a complaint or grievance, nor was there a designated grievance official identified. The Administrator confirmed that grievance forms and records were kept in his office, and upon review, only one grievance record was found, which was incomplete as the follow-up section was left blank. The Administrator acknowledged that the grievance had not been followed up for resolution, despite the facility's policy requiring actions to resolve complaints within 72 hours of receipt.
Failure to Safeguard Resident Information
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. Observations revealed an unattended medication cart with a built-in computer monitor displaying an Electronic Health Record (EHR) of a current resident, including personal identifiable information such as full name, room number, birthday, code status, and medication/treatment orders. This occurred on multiple occasions, with the computer screen left unlocked and unattended, allowing residents, visitors, and staff to pass by and potentially view the confidential information. An anonymous staff member confirmed that the computer screen should have been locked to protect residents' confidential information. The facility's Administrator acknowledged that the computer monitor should be locked when not attended by the responsible staff member.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the fourth quarter of 2024. The report triggered for excessively low weekend staffing and a lack of 24-hour licensed nursing coverage. Despite the weekend staffing schedules showing equal staffing during the week and weekends, inaccuracies were identified due to time sheets not being turned in for a traveling nurse and agency staff hours not being reported correctly. The Assistant Administrator acknowledged that time sheets were not appropriately sent to the billing email, leading to the inaccuracies. The Administrator confirmed these issues, noting that the facility's accountant was responsible for submitting the staffing data to CMS, and the expectation was for accurate data to be reported.
Facility Lacks Effective QAPI Program Leading to Repeated Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies in various areas over several years. These deficiencies included issues with Medicaid/Medicare coverage notices, transfer/discharge notices, bed hold policies, accuracy of assessments, care plan development and implementation, accident hazards, tube feeding management, psychotropic medication use, significant medication errors, drug storage, food sanitation, infection control, and immunizations. The facility's inability to provide current Performance Improvement Plans (PIPs) or tracking mechanisms for these plans further highlighted the lack of a comprehensive QAPI program. The Administrator acknowledged the repeated deficiencies and attributed some of the issues to staff turnover and the facility's reorganization under Chapter 11, which diverted focus from quality improvement efforts. Despite completing Plans of Corrections (POCs), the facility did not consistently create PIPs to address and mitigate repeat deficiencies. The Administrator admitted that the facility was not utilizing QAPI to its fullest extent, and the QAPI team only discussed concerns raised in Standup Meetings without implementing effective interventions or root cause analyses.
Deficiency in QAPI Implementation and Documentation
Penalty
Summary
The facility failed to establish and implement effective written policies and procedures for its Quality Assurance and Performance Improvement (QAPI) plan. The facility's policy, titled QAPI Policy and Protocol, lacked effective procedures for identifying, collecting, using, and monitoring data across all departments. It also did not specify how the facility would report, track, investigate, and analyze adverse events or problem-prone concerns. Furthermore, the policy did not describe the development of corrective actions to effect change at the systems level to prevent issues related to quality of care, quality of life, and safety. Additionally, the document did not outline how the facility would monitor the effectiveness of its Performance Improvement Plans (PIPs) to ensure sustained improvements, nor did it include the required committee members. During an interview, the Administrator admitted that the facility was unable to provide any ongoing QAPI programs, implementations, or activities for review, either in paper or electronic format. The last PIP was related to Enhanced Barrier Precautions (EBP) in April 2024, but no further documentation or details of PIPs developed from submitted paperwork were available. The Administrator stated that the QAPI process was managed similarly to the daily Standup Meeting, where concerns such as infection control, falls, upper respiratory infections, urinary tract infections, and insufficient intakes were discussed. However, the Administrator acknowledged that the facility did not utilize QAPI to its fullest potential and that the policy should be updated annually.
Deficiency in QAPI Committee Meeting Documentation and Attendance
Penalty
Summary
The facility failed to maintain records of Quality Assurance and Performance Improvement (QAPI) committee meetings for one of the three quarters reviewed, and did not ensure the required attendees were present. The facility's documentation showed that meetings were held on two specific dates, but no further quarterly documentation was provided for the previous three quarters. The facility's QAPI policy was undated and did not include the Infection Preventionist and Medical Director as required members. The QAA Committee document listed several members, but also omitted the Infection Preventionist. The Administrator acknowledged discrepancies between the QAPI Policy and Protocol and the QAA Committee document, stating that the policy was outdated and should be updated annually. The Administrator explained that the core members of the QAPI committee included the Administrator, Director of Nursing (DON), MDS/Care Plan Coordinator, Social Services/Housekeeping/Laundry, and Dietary Supervisor, but noted that the Medical Director should generally be present. The Administrator admitted that there should have been four attendance sheets since the previous survey, but could not provide additional documentation, as it was managed by Social Services personnel. The Administrator also stated that the facility did not utilize QAPI to its highest potential and abilities, and there had been no QAPI plans developed related to meeting frequencies or attendance.
Call Light System Failure in LTC Facility
Penalty
Summary
The facility failed to maintain a functioning call light system, which is essential for residents to request assistance. Resident #194, who has no cognitive impairment and suffers from acute respiratory failure with hypoxia and asthma, reported that her call light was not working properly. She mentioned that this issue persisted in her previous room as well. Staff members confirmed that the call light system frequently malfunctions, requiring resets, and that when it fails, none of the call lights in the facility work. The problem has been ongoing since December, and the facility's administrator acknowledged that the system's software is outdated and requires archiving to prevent it from becoming overwhelmed. The administrator also revealed that the call light system's failures are more prevalent in the south wing, with some rooms losing connection to the wireless system. Despite having purchased bells as a backup, they have not been distributed to residents. Complaints from residents and family members about delayed response times due to the system's failure have been noted. The administrator admitted that the facility occasionally loses the IP address for the call light system, further complicating the issue. Currently, no residents have been provided with the backup bells, leaving them without a reliable means to call for assistance.
Failure to Provide Mandatory Abuse Reporting Training
Penalty
Summary
The facility failed to provide adequate training to its staff on the identification and reporting of abuse, neglect, exploitation, and misappropriation of resident property. This deficiency was identified through a review of facility documents, staff interviews, and policy review. Specifically, there was no documentation or certificate of completion for the required Dependent Adult Abuse/Mandatory Reporter training for Staff I and Staff M, both Certified Nurse Assistants (CNAs). The facility's policy mandates that each employee complete two hours of training related to the identification and reporting of dependent adult abuse within six months of initial employment and an additional two hours every five years. During the investigation, Staff E, the Assistant Administrator, acknowledged the lack of documentation for the completed training for both staff members. Staff E mentioned that Staff M was not on the list requiring an update, while Staff I was on the list and had been asked to complete the training. However, there was no evidence of completion. The Administrator confirmed that the facility's expectation was for the training to be completed within the first six months of employment. The facility reported a census of 43 residents at the time of the survey.
Deficiency in CNA In-Service Training
Penalty
Summary
The facility failed to provide the required in-service training for Certified Nurse Assistants (CNAs) to ensure continued competence, as mandated by regulations. Specifically, the facility did not complete the necessary 12 hours of annual training for CNAs, which should include topics such as resident rights, dementia care, infection control, and behavioral health. A CNA, identified as Staff D, confirmed that she had not received regular in-service training in these areas during her year and a half of employment. The Director of Nursing (DON) acknowledged the absence of annual training and stated that this issue had been identified and reported to the Administrator. The Administrator also confirmed that the required yearly training for CNAs had not been completed, as per regulatory requirements.
Failure to Document Advance Directives Correctly
Penalty
Summary
The facility failed to maintain accurate documentation of residents' advance directives, specifically regarding Do Not Resuscitate (DNR) orders, for three residents. Resident #24 entered the facility with hospice services and had a DNR status documented in the Medication Administration Record (MAR). However, the Electronic Health Record (EHR) lacked a signed Resident Advance Directives form reflecting the DNR wishes, and it was not signed by the physician. The Director of Nursing (DON) confirmed the absence of the form in both the EHR and physical chart, although it was later found signed by the DON and verbally verified with the Power of Attorney (POA) but still lacked the physician's signature. For Resident #9 and Resident #194, both with moderate cognitive impairment, the Resident Advance Directive forms indicated a DNR status but were not signed by a physician. The facility's policy, revised on 10/19/23, requires physician signatures for DNR orders, which were not obtained for these residents. The Administrator expected the code status to be verified during admission and the necessary paperwork to be faxed promptly, which was not adhered to in these cases.
Failure to Verify CNA Certification
Penalty
Summary
The facility failed to ensure that a nurse aide, Staff I, who had been employed for more than four months, completed a state-approved training and competency evaluation program. Staff I was hired on July 29, 2024, but there was no CNA certificate or proof of completion of the required training and competency evaluation in her employee file. The State Agency website also did not list Staff I as certified, indicating no test had been taken, and her certification status was blank. This oversight was identified during a review of employee files, staff interviews, and the facility's policy review. Staff J, the Administrative Assistant, acknowledged that the facility should have reported Staff I's employment to the State Agency and ensured her certification. Staff E, the Assistant Administrator, confirmed that Staff I had worked on the floor as a CNA despite her certification having lapsed. The issue was initially identified by a previous administrative assistant but was not followed up on by subsequent staff. The facility's policy required verification of CNA certification before allowing aides to work on the floor, which was not adhered to in this case. The Administrator admitted that the facility should have verified Staff I's certification within the first four months of her employment and ensured the test results were uploaded to the State Agency website.
Failure to Identify Target Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to identify target behaviors for psychotropic medication use for five residents, leading to deficiencies in medication management. Resident #33, with moderate cognitive impairment and diagnoses of Non-Alzheimer's Dementia and depression, was prescribed multiple psychotropic medications without specified target behaviors. The care plan did not address the resident's target behaviors of depression or the use of antidepressant and psychotropic medications for Vascular Dementia. The Director of Nursing acknowledged the absence of target behaviors in the medication orders, and the facility lacked a policy for identifying target behaviors. Resident #16, also with moderate cognitive impairment, was prescribed an antidepressant for depressive disorder, yet the care plan did not include target behaviors or non-pharmacological interventions. The resident exhibited verbal aggression towards staff, but no interventions or coping skills were implemented. Progress notes failed to document any behaviors in the past 30 days, indicating a lack of monitoring and intervention. Similarly, Residents #2, #22, and #194 were prescribed various psychotropic medications without documented target behaviors in their care plans or physician orders. These residents had varying levels of cognitive impairment and were prescribed medications for conditions such as depression, anxiety, and vascular dementia. The facility's failure to document target behaviors and implement appropriate interventions for these residents highlights a systemic issue in medication management and care planning.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its abuse and neglect policy by not completing background checks prior to staff employment and failing to provide annual abuse training. Specifically, a Certified Nurse Assistant (CNA), identified as Staff I, was hired on 7/29/24 without a current background check, as the last check was completed on 7/25/22. This oversight was acknowledged by the Assistant Administrator and the Administrator, who both confirmed that a background check should have been completed before Staff I's employment. Additionally, the facility did not adhere to its policy regarding annual abuse prevention training. An incident involving a Licensed Practical Nurse (LPN), identified as Staff A, was reported where the LPN held a resident's hands down and forced medication administration despite the resident's refusal. The LPN confirmed the incident and stated that no written disciplinary actions or additional training on abuse prevention were provided by the Administrator. Furthermore, the LPN's personnel file lacked documentation of annual abuse prevention training, which was confirmed by the Administrator as a failure to follow the facility's policy.
Improper Food Storage and Expiration Management
Penalty
Summary
The facility failed to store food in accordance with professional standards, as observed during a survey. In the dry storage room, several food items were found with expired dates, including a sealed bag of pretzels, a bag of dry gravy mix, and cans of chicken noodle and tomato soup. Additionally, items such as saltine crackers and cereal were removed from their original packaging and stored without receiving or expiration dates. In the walk-in freezer, bags of fried rice were also found without receiving or expiration dates. Staff F, the Certified Dietary Manager (CDM), acknowledged the expired items and stated that the facility did not have a policy on maintaining expiration dates for food removed from boxes. The Administrator later confirmed that items in dry storage should be checked more frequently, either monthly or quarterly, to prevent serving expired food. The facility's undated Storage Policy indicated that items out of their original packaging could only be kept for three days after opening, and all items must have an open date after opening. The policy also required daily inspections by dietary staff and twice-weekly checks by the CDM and assistant, with monthly inspections by the Registered Dietitian. However, these procedures were not followed, leading to the presence of expired and improperly stored food items.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to provide comprehensive care plans for several residents, which included necessary goals, desired outcomes, and interventions for various medical treatments and conditions. For Resident #1, the care plan lacked focus, desired outcomes, or interventions related to the use and care of a urostomy, despite a physician's order for its management. Staff acknowledged the absence of a care plan for this aspect of the resident's care. Resident #2's care plan did not address the use of psychotropic, antipsychotic, or diuretic medications, even though the resident was prescribed several such medications. The Director of Nursing (DON) confirmed that the facility's expectation was for care plans to include goals, desired outcomes, and interventions for these medications. Similarly, Resident #194's care plan was missing focus and interventions for psychotropic and opioid use, despite the resident being prescribed these medications. Other residents, such as Resident #16, had care plans that failed to include specific interventions for verbal aggression and coping skills, and Resident #23's care plan incorrectly referenced anticoagulant medication instead of antiplatelet therapy. Resident #33's care plan did not identify target behaviors or focus areas related to the use of antidepressant and psychotropic medications. The facility's policy indicated that all pertinent information should be considered for care plan development, but it did not ensure that goals and interventions directly related to the identified focus areas.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plans in a timely manner for three residents, leading to deficiencies in reflecting their current conditions and necessary interventions. Resident #19 experienced a significant change in status with the initiation of hospice care, yet the care plan was not updated to include hospice or end-of-life care interventions. The Director of Nursing acknowledged that the care plan should have been updated to reflect these services. Resident #23's care plan did not document physician orders related to wound care, such as keeping the right foot dressing in place and covering it for showers. Additionally, the care plan failed to include the intervention of wearing an off-loading boot at all times and did not address the resident's scooter mobility and safety interventions after an incident. The MDS Coordinator and Administrator acknowledged these omissions, noting that specific interventions should be reflected in the care plan. Resident #33's care plan lacked instructions for staff to follow in case of alarm or call light system failures. The facility had been experiencing issues with the call light system, which sometimes did not function properly. The Administrator and DON acknowledged the problem, and staff confirmed that the ghost alarm, which was connected to the call light system, would not work if the system was down. The facility's policy did not include procedures for updating care plans, contributing to the oversight.
Failure to Follow Physician's Order for Mitt Use
Penalty
Summary
The facility failed to enter and follow a physician's order for a resident with severe cognitive impairment, who had an order to wear a mitt/glove on the right hand daily. The order, documented on 10/30/24, specified that the mitt should be removed for hygiene and range of motion at least twice daily. However, the Treatment Administration Record for February 2025 showed no entry of this order. The resident's mother provided the mitts, but reported that the facility considered them a restraint and that the mitt was never on the resident when she visited. Staff interviews revealed that the mitt was only applied once, and the Director of Nursing (DON) acknowledged that the order was not entered into the Electronic Health Record (EHR) as expected. The DON also noted that assessments should have been completed twice daily when the mitt was used, but this was not done. The resident reportedly disliked the mitt and frequently refused it, which was documented by a Licensed Practical Nurse (LPN) in the progress notes.
Failure to Assess and Document Restraint Use
Penalty
Summary
The facility failed to provide quality nursing care by not completing an assessment related to the use of a restraint for a resident with severe cognitive impairment. The resident had a physician's order to use a mitt/glove on the right hand daily, which was intended to prevent the resident from pulling out a gastrostomy tube. The order specified that the mitt should be removed for hygiene and range of motion at least twice daily. However, the facility did not complete the necessary restraint assessment, and the order was not entered into the electronic health record (EHR) as expected. The Director of Nursing (DON) and the Licensed Practical Nurse (LPN) MDS Coordinator acknowledged the oversight, noting that the resident could not remove the mitt independently, classifying it as a restraint. The resident's mother had provided the mitts, but the facility did not conduct an evaluation or assessment by an occupational therapist, as required by the facility's protocol for the use of physical restraints. The protocol mandates that a licensed therapist or care plan team should complete a screening to determine the least restrictive device, and the restraint should be released and the resident repositioned approximately every two hours, which was not documented as being done.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate and report an allegation of abuse involving a resident with severe cognitive decline and multiple medical conditions, including non-Alzheimer's dementia and hemiplegia. The incident involved a staff member allegedly holding the resident's hands down and forcing medication. The facility did not submit a thorough investigation to the State Survey Agency within the required five working days. The investigation was incomplete as the administrator did not interview other residents or staff, nor did they initiate training on abuse prevention. The staff member involved, an LPN, was placed on administrative leave but returned to work without completing mandatory training. The facility's policy required separation between the accused employee and the resident until the investigation was concluded, but this was not maintained. The administrator failed to ensure the staff member did not provide care to the resident after returning to work, and the investigation results were not adequately documented or reported to the appropriate authorities.
Medication Labeling Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards, leading to discrepancies between medication labels and the Medication Administration Record (MAR). During a medication administration observation, a Registered Nurse (RN) administered insulin to a resident without verifying the label on the insulin pen, which indicated a different dosage than the MAR. The RN admitted to not checking the labels and was unaware of the discrepancy. The Director of Nursing (DON) confirmed that the pharmacy did not reprint new labels for medications already on hand, and the facility relied on the MAR for dosage instructions. In another instance, a Licensed Practical Nurse (LPN) received a verbal order for a change in dosage for a resident's MS Contin medication from a hospice nurse. The order was to change from 15 mg to 30 mg, but the times for administration were not specified. The LPN noted that the hospice nurse instructed the use of two 15 mg tablets until the 30 mg tablets were available, but the facility did not have a written order for the 30 mg dosage. The DON acknowledged that the facility did not have stickers to indicate changes in medication orders and that the pharmacy had not provided new labels for some time. The Consultant Pharmacist stated that the pharmacy could not provide new labels for medication changes due to regulations, but they could provide stickers indicating a change in directions. However, the facility did not have these stickers, and the DON confirmed that there was no policy or procedure for handling label changes. The lack of proper labeling and communication regarding medication changes led to confusion among staff and potential medication administration errors.
Failure to Provide Timely Notification of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide timely notification of financial responsibility to residents and their families when Medicare Part A services were scheduled to be discontinued. For Resident #11, who had severe cognitive impairments and required assistance with daily activities, the facility did not provide the Notice of Medicare Non-Coverage (NOMNC) 48 hours in advance of the discharge from therapy services. The NOMNC was signed by the resident on a date after the services had already been terminated, indicating a delay in communication. Similarly, for Resident #15, who also had severe cognitive impairment and required significant assistance, the facility did not provide the necessary documentation, including the Skilled Nursing Facility Advanced Beneficiary Notice (ABN) and the NOMNC. The facility's records did not show that these forms were issued or signed by the resident or their power of attorney. The Assistant Administrator acknowledged issues with the completion of ABN notifications, and the facility lacked an Advanced Beneficiary Notice Policy, contributing to the deficiency.
Inaccurate Medication Assessment on MDS
Penalty
Summary
The facility failed to accurately assess a resident's medication use during the observation period of the Minimum Data Set (MDS). Specifically, the MDS for a resident documented the use of insulin therapy, which was incorrect as the resident was actually prescribed Ozempic, a non-insulin medication. This error was identified as a coding mistake by the Licensed Practical Nurse (LPN)/MDS Coordinator and acknowledged by the Director of Nursing (DON). The facility's policy requires the MDS to accurately reflect a resident's needs, care, and medication, which was not adhered to in this instance.
Failure to Complete PASRR for Resident with New Mental Diagnoses
Penalty
Summary
The facility failed to complete a Pre-Admission Screening and Resident Review (PASRR) for a resident who was diagnosed with new mental disorder diagnoses since admission. The resident, identified as Resident #3, had a Minimum Data Set (MDS) indicating no cognitive deficit but had diagnoses of Anxiety Disorder, Depression, Psychotic Disorder, and PTSD. The resident was on multiple medications for depressive disorder, including Amitriptyline, Klonopin, Prozac, and Trazadone. Despite these diagnoses and medications, the PASRR Level I Screen Outcome did not show evidence of a serious mental illness or intellectual or developmental disability requiring PASRR intervention. However, the facility's policy required a status change submission for further evaluation if discrepancies were found. The electronic health record (EHR) revealed additional medical diagnoses for the resident, including unspecified psychosis, other malaise, dizziness, hallucinations, and alcohol abuse. The Director of Nursing (DON) acknowledged that a PASRR should have been completed with the new diagnoses added in 2023. The facility's policy stated that when there is a change in mental status or behaviors, the resident should be assessed for submitting a Level II PASRR. The Administrator became aware of the PASRR concern during the survey and recognized the need to implement a process to ensure PASRR completion when new diagnoses are added by a physician.
Failure to Respect Resident's Rights During Medication Administration
Penalty
Summary
The facility failed to treat a resident with dignity and respect during medication administration. A resident with severe cognitive decline, non-Alzheimer's dementia, hemiplegia, seizure disorder, and ataxia following a cerebral infarction was involved. The resident required total dependence on staff for activities of daily living. A nurse's progress note documented an incident where a staff member held the resident's hands down and forced medications. During an interview, an LPN admitted to holding the resident's hands to prevent arm flinging and acknowledged that the resident had a history of refusing medications. The LPN stated that the appropriate action would have been to wait until the resident was willing to take the medications. The Director of Nursing expected staff to document medication refusals, but the facility's medication administration policy did not provide guidance for handling medication refusals.
Failure to Maintain a Homelike Environment Due to Unemptied Commode
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for a resident by not ensuring the timely emptying of a commode, which was left with feces and urine for at least 8 hours. The resident, who had moderate cognitive impairment, was observed to have a commode in her room due to the toilet being taped shut. This was a result of the resident's history of flushing inappropriate items down the toilet, causing plumbing issues. Despite the presence of the commode, it was not emptied regularly, leading to a strong odor of urine and feces in the room. Staff interviews revealed a lack of awareness and training regarding the care and maintenance of the commode. The Assistant Administrator was unaware of the toilet being taped shut, and several CNAs admitted to not having checked or emptied the commode during their shifts. The CNAs stated that they were expected to empty the commode but had not received specific training or instructions on how often this should be done. The Administrator and Director of Nursing (DON) both acknowledged that the commode should be checked and emptied every 2 hours, but this expectation was not communicated effectively to the staff. The Administrator explained that the decision to use a commode was made to prevent further plumbing issues caused by the resident flushing inappropriate items. However, the lack of a clear protocol for maintaining the commode led to the deficiency. The Administrator and DON both expressed expectations for regular checks and emptying of the commode, but these were not implemented, resulting in the resident's room being left in an unsanitary condition.
Failure to Notify PCP of Resident's Treatment Refusal
Penalty
Summary
The facility failed to notify the primary care provider (PCP) of a resident's refusal to take newly scheduled breathing treatments. The resident, who had severely impaired cognitive skills and multiple diagnoses including cerebral infarction, atrial fibrillation, pneumonia, stroke, dementia, seizure disorder, anxiety, depression, and gastrostomy status, was prescribed nebulizer treatments three times a day for five days following a visit to the PCP. Despite the resident's refusal to take these treatments on multiple occasions, as documented in the progress notes and medication administration record, the facility did not inform the PCP of these refusals. The Director of Nursing (DON) acknowledged that the facility's policy required physician notification only in cases of significant change, and noted that the resident was known for refusing treatments. The PCP confirmed that he was not notified of the refusals and stated that it would have been beneficial to be informed. The facility's policy on physician notification indicated that any need outside the current doctor's orders should prompt notification, but the DON indicated that the refusals did not meet the criteria for notification unless specified in the order.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Two residents who were cognitively impaired and dependent on staff for personal care did not receive bathing assistance at least twice weekly as required by facility policy. Facility records showed multiple instances where bathing was documented as refused or not applicable, resulting in gaps of 6, 7, and 11 days between baths. The care plan for one resident specified total dependence on staff for bathing, and the facility’s policy required showers to be offered at least twice weekly and on the next available day if missed. The DON reported that staff are expected to continue offering showers and try different approaches after refusals, but the documented bathing intervals did not reflect this practice.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
A resident with COPD, pneumonia, and respiratory failure was transferred to the hospital for acute respiratory distress and later deemed medically ready for discharge, but the facility delayed readmission by three days due to staffing and admission timing practices. Facility staff, including an RN, MDS coordinator, ADON, DON, and Administrator, reported that they avoided weekend and evening admissions, required two nurses for admissions, and were concerned about entering medication orders into the EMR in time for pharmacy delivery when only one nurse was on duty. They did not notify the provider about the planned discharge back, did not arrange alternative pharmacy or transport options, and cited shared transport and lack of additional nurses as reasons the readmission was not feasible, despite the facility’s stated commitment to 24-hour nursing care and medication management.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
Failure to Provide Twice-Weekly Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance at least twice weekly, as required by its own policy, for two residents who were dependent on staff for bathing. For one resident with anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive impairment, the MDS documented total dependence on staff for bathing. Facility documentation showed that bathing was recorded as refused on one date, with actual baths provided on dates that resulted in a 6‑day interval without a bath on two separate occasions. The resident’s care plan indicated the resident was totally dependent on staff to provide a bath as necessary. For another resident with diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, facility records showed multiple dates where bathing was documented as refused or as not applicable. Review of the Follow Up Question Report demonstrated several extended gaps between baths: 6 days on two occasions, 7 days on one occasion, and 11 days on another, despite the facility policy requiring showers to be offered at least twice weekly and, if missed, to be offered on the next available day. In an interview, the DON stated that when a resident refuses a shower, staff are expected to continue to offer, try multiple times, try a different person, and continue to try the next day until the resident bathes, which was not reflected in the documented bathing intervals for these two residents.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Delayed Hospital Readmission Due to Insufficient Nursing Staff and Admission Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and related processes to support the timely readmission of a hospitalized resident, resulting in a three-day delay in the resident’s return. The resident had moderately impaired cognition, with a BIMS score of 12/15, and medical diagnoses including COPD with acute exacerbation, pneumonia, and respiratory failure. The resident was transferred to the hospital after staff observed labored respirations, use of accessory muscles, diaphoresis, an oxygen saturation of 85% on room air, and wheezing, with improvement after oxygen was applied but continued labored breathing. Hospital records show the resident was admitted and later determined medically stable and ready for discharge, with documentation that the patient was planned for discharge but was not accepted back to the facility due to timing issues and would remain in the hospital over the weekend. Hospital progress notes documented that the resident was medically ready for discharge and that discharge was planned but not completed because the facility would not accept the resident later in the day. A hospital case management/social work note indicated confirmation that the facility could take the patient on the day the resident ultimately returned. The facility’s EHR showed the resident’s billing status changed to STOP BILLING on the date of hospital transfer and back to active several days later, corresponding to the delayed readmission. The resident reported spending three days in the hospital before being able to return to the facility. Multiple staff interviews described facility practices that contributed to the delay in readmission. An RN stated the facility tried not to do admissions on weekends and did not want admissions after 2 p.m. so nurses could complete admission tasks and enter medications into the computer in time for pharmacy delivery. The MDS Coordinator stated the facility liked residents readmitted before 2 p.m. to obtain medications, that the hospital had informed them the resident would not return until early evening, and that the facility needed two nurses in the building for an admission; the coordinator also stated the facility did not do admissions on weekends and was unsure about using another pharmacy or family to obtain medications. The ADON and DON both stated that with only one nurse on duty, a readmission later in the day was not feasible due to the time needed for admission assessments and medication entry, and they cited concerns about not having medications on time and the workload of one nurse caring for existing residents and completing a readmission. The DON further stated the facility did not accept evening or Saturday admissions for safety reasons, did not notify the provider about the planned discharge back to the facility, and did not explore hospital-supplied medications or alternative transport options, while acknowledging the presence of on-call nurses. The Administrator confirmed that with only one nurse, a readmission was considered not doable. The facility lacked written transportation or readmission policies and relied on general CMS and Resident Rights guidance, while its Resident Handbook stated residents receive individualized 24-hour nursing care and medication management.
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