The Village Of Ackley

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately code 1 of 1 MDS assessments for a resident with a PASRR Level II outcome. Resident #2’s MDS assessment dated 12/11/25 identified that she did not have a state level II PASRR serious mental illness and/or intellectual disability or related condition, even though the assessment also documented a BIMS score of 15 and diagnoses of depression, schizophrenia, and cognitive communication deficit. Her PASRR notice of nursing facility approval dated 6/16/25 reflected that she experienced a significant change in status and met criteria for Level II with approved specialized services. During interviews, the Administrator stated that when the MDS was completed in March 2025 there were concerns about its accuracy by the MDS Coordinator at the time, who no longer worked at the facility. Staff A, the RN Assessment Coordinator responsible for completing the MDS, stated she followed the RAI manual and normally relied on communication from the facility when a resident changed from Level I to Level II PASRR status. Staff A acknowledged the MDS lacked documentation of the Level II and confirmed Resident #2’s Level II was approved on 6/16/25. The DON also stated Resident #2 met criteria for a Level II but did not have evidence that the change in status was communicated to Staff A, and expected staff to code the MDS accurately.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to clean the kitchen convection oven, stove top griddle, sink, cabinet under the sink, and electric griddle. During an initial kitchen walkthrough, the cabinet under the sink next to the ice machine had a brown-like sticky discoloration along the cabinet doors, the height of the cabinet, and the top of the doors. The sink next to the ice machine had mineral deposit build-up on the faucet, handles, and down the back of the sink. The Bakerspride oven had a brown-like sticky discoloration on the doors, and thick black discoloration was observed on the Vulcan stove top, Vulcan stove top griddle, and Presto flat electrical pan. On subsequent observations, the sink, cabinet, Vulcan stove, Vulcan stove top griddle, Bakerspride oven, and Presto electric griddle remained in the same condition. A Dietary Aide stated the griddle on the stove was not used, that the flat electric pan was cleaned weekly, and that it was getting bad. The Dietary and Housekeeping Manager stated they tried to get everything clean, used scratch pads to clean the Vulcan stove on Sundays, and did not know how to scrub the Presto electric flat griddle. The Administrator stated he expected a clean kitchen with properly trained staff. Review of the facility's weekly cleaning list showed no documentation that the stove top burners were cleaned and did not include the sink next to the ice machine, the cabinets, the oven, or the griddles.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident was free from neglect after a fall. Resident #2 had severe cognitive impairment with a BIMS score of 6, diagnoses of Parkinson's disease, anxiety disorder, and depression, and required substantial to maximal assistance for sit-to-stand and was dependent for chair/bed-to-chair transfers. The care plan identified the resident as at risk for falls and directed staff to use non-skid footwear, keep the wheelchair lowered, place non-skid strips in front of the chair and bed, and keep the call light within reach and encourage its use. On 8/16/25, a progress note documented the resident lying prone on the floor between the bathroom and recliner, yelling for help and stating, "I'm scared, I'm scared." The note stated the resident had pain to both knees and the right arm, with small superficial abrasions to both elbows and both knees. The resident was assisted from the floor by three staff using a gait belt and front wheeled walker. The note also documented the call light was within reach but not activated, the walker was within easy reach, and the room was free of clutter. Former Staff D reported she had assisted the resident from the bed to a lift recliner, removed the gait belt, turned to remove her gown, and then saw the resident on the floor. Staff D stated she panicked, exited the room, and left the facility without assisting the resident or reporting the fall to the nurse. The resident said she had been yelling for help and was scared, and could not recall whether a staff member had been in the room at the time of the fall. Staff B reported she was alerted by another resident and then assessed the resident, and the DON reported she was later informed that Staff D had left before the end of the shift and had not reported the fall before leaving. The facility policy required residents to receive adequate supervision and assistance devices to prevent accidents, but the policy lacked direction for staff in reporting falls.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an allegation of neglect to the Iowa Department of Inspection, Appeals, and Licensing (DIAL) within the required time frame for one resident. Resident #2 had a BIMS score of 6, indicating severe cognitive impairment, and required substantial to maximal assistance for sit-to-stand transfers and was dependent for chair/bed-to-chair transfers. The resident also had diagnoses of Parkinson's disease, anxiety disorder, and depression, and the care plan identified the resident as being at risk for falls with directions for non-skid footwear, a lowered wheelchair, non-skid strips, and ensuring the call light or pendant was within reach. On 8/16/25, former CNA Staff D assisted Resident #2 from the bed to a lift recliner using a gait belt and walker. Staff D reported removing the gait belt and turning to remove a protective gown when she heard a noise and saw Resident #2 lying on the floor on her right side with the walker beside her. Staff D stated the resident was conscious, but she panicked, left the room, and exited the facility without assisting the resident or notifying the nurse of the fall. Staff D acknowledged she had been trained on incident reporting and that her actions were wrong. Staff B, RN Nurse Mentor, reported being alerted that Resident #2 needed help and assessed the resident before calling for assistance to get the resident off the floor. Staff B notified the DON, who then learned that Staff D had left the facility before the end of the shift. The DON later acknowledged that Staff D's failure to assist and report met the facility's definition of neglect and that the incident should have been reported to DIAL. The facility's incident records did not include a report to DIAL for the allegation of neglect after the facility became aware of Staff D's actions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the Long Term Care (LTC) Ombudsman of a resident's transfer to the hospital, as required. This deficiency was identified during a clinical record review and staff interview, which revealed that the facility did not inform the LTC Ombudsman about the hospitalization of a resident, referred to as Resident #9. The resident was admitted to the hospital on May 27, 2024, and returned to the facility on May 30, 2024. The facility lacked documentation of the required notification to the LTC Ombudsman regarding this transfer. During interviews, the Administrator acknowledged the responsibility for sending such notifications and admitted that the notifications for Resident #9 and other residents transferred or discharged in April and May 2024 were not submitted. Additionally, the facility did not provide a policy for the required notification to the LTC Ombudsman for resident transfers and discharges.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident with a new mental health diagnosis. The resident, identified as Resident #19, was diagnosed with post-traumatic stress disorder (PTSD) effective November 10, 2023, and was receiving antipsychotic medication for PTSD-related nightmares. The resident's Minimum Data Set (MDS) assessment and care plan reflected this diagnosis and medication use. However, the PASRR completed on January 20, 2023, only included a negative Level 1 screening and lacked documentation of any mental health diagnosis. The facility's policy required a change in status and a Level II PASRR evaluation submission when a new mental health diagnosis was made, which was not completed in this case. During an interview, the Administrator acknowledged the oversight in not completing the Level II PASRR evaluation for the resident's new PTSD diagnosis.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to submit accurate direct care staffing information to the CMS Payroll Based Journal (PBJ) Staffing Data Report for the quarter of July 1, 2024, to September 30, 2024. The report triggered for excessively low weekend staffing and for failing to maintain licensed nursing coverage 24 hours a day for 26 days during July and August 2024. The facility's staffing reports and interviews revealed that the facility used outside staffing agencies to cover open nursing shifts not filled by facility employees. However, the Administrator did not validate the PBJ data after submission to ensure it accurately reflected the facility's records. The facility switched time clocks from Matrix to Dayforce during the quarter, which may have contributed to the discrepancies in the reported data. The Administrator acknowledged that the PBJ reporting did not match the daily nursing schedules and confirmed that the verification of outside staffing agency hours was done through email correspondence. Additionally, the facility did not provide a policy for the accurate submission of PBJ Staffing Data, and the Administrator did not follow recommended steps to verify the data submission, such as checking the My Submissions page or running validation reports.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to treat a resident with dignity and respect, as required by their Resident Rights policy. The incident involved a resident with severe cognitive impairment, who had been admitted following a short-term hospitalization and had a history of stroke, non-Alzheimer's dementia, depression, and a psychotic disorder. During a transfer to a wheelchair, the resident became distressed, screaming and calling for help. In response, a certified nursing assistant (CNA), identified as Staff B, used inappropriate language, telling the resident to "shut the fuck up" and made a distressing comment about the resident's deceased mother. The incident was reported by another CNA, Staff A, to the Director of Nursing (DON), who then assessed the resident and found no physical injuries. Staff B admitted to using inappropriate language and was subsequently removed from the facility and terminated. The facility's failure to document the date Staff B received training on Resident's Rights was also noted. The facility's policy emphasizes treating residents with respect and dignity, which was not upheld in this instance.

Penalty

Inspection fine: $24,668

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate nursing supervision to prevent accidents and injuries for a resident who experienced multiple falls. The resident, who had a history of falls and various medical conditions including Parkinson's, dementia, and fibromyalgia, required partial to moderate assistance with transfers and toilet use. Despite therapy recommendations for two staff members to assist the resident and not leave her alone in the bathroom, the care plan was not updated to reflect these recommendations, leading to inadequate supervision and assistance. In June, the resident experienced four falls, resulting in injuries such as a right ankle injury and a skin tear on the right elbow. The falls were attributed to the facility not adhering to therapy recommendations, as evidenced by the care plan directing only one staff member to assist with transfers and ambulation. The facility's documentation lacked timely fall risk assessments and failed to include necessary fall interventions after each incident, further contributing to the resident's risk of falls. Interviews with staff revealed a lack of communication and adherence to updated care plans, with staff members unaware of the therapy recommendations. The facility's incident/accident prevention policy was not followed, as the care plan did not include updated fall interventions, and the facility did not consistently review and modify interventions after each fall. This oversight resulted in repeated falls and injuries for the resident, highlighting deficiencies in the facility's supervision and care planning processes.

Penalty

Inspection fine: $24,668

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct appropriate assessments, interventions, and timely physician notification for a resident who experienced difficulty swallowing, poor oral intake, and mouth pain, resulting in weight loss and hospitalization for acute kidney injury, dehydration, and MRSA pharyngitis. The resident began having difficulty swallowing and was sent to the emergency room but continued to experience these issues upon returning to the facility. Despite the resident's continued decline, the facility did not notify the primary care provider until much later, when an order for speech therapy was given. The resident's care plan included monitoring food and fluid intake, providing adaptive equipment, and recording weight changes, but the facility did not document interventions to assist with self-feeding or improve oral intake. The clinical record lacked documentation of a speech therapy evaluation and treatment, as ordered by the physician. Staff interviews revealed that the resident had very dry lips, difficulty swallowing, and poor intake, but these issues were not adequately addressed or communicated to the physician or family. The facility's hydration program policy outlined steps to ensure adequate fluid intake and prevent dehydration, but the resident's fluid intake was insufficient, and the facility failed to document meal and fluid intakes consistently. The resident's family expressed concerns about the resident's condition, and the facility eventually sent the resident to the hospital, where they were diagnosed with acute renal failure and dehydration. The facility did not notify the physician of the resident's poor meal and fluid intakes or recent weight loss in a timely manner.

Penalty

Inspection fine: $24,668

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician and family for a significant change in condition for two residents. Resident #1 experienced an unwitnessed fall in her room, which was documented in the Facility Event Report. Despite the fall, the staff delayed notifying Resident #1's family until two days later, when the family inquired about a bruise on her chin. Additionally, Resident #1 exhibited signs of confusion, slurred speech, and difficulty swallowing, which were not promptly communicated to her physician. The facility only notified the physician of these issues a week later, after Resident #1 had been sent to the emergency room and returned without a definitive diagnosis. Resident #1 also experienced significant weight loss over a period of 30, 90, and 180 days, with a noted decline in oral intake following her fall. Despite these concerning changes, the facility did not notify Resident #1's physician or family about her poor meal and fluid intakes and the associated weight loss until much later. The delay in communication and lack of timely intervention contributed to the deficiency in care provided to Resident #1. Resident #4 also experienced an unwitnessed fall in her room, resulting in a bruise to her right flank. The facility failed to document any notification to Resident #4's physician or family regarding the bruise, which was identified after the fall. The facility's policy required notification of the resident's representative and physician for serious injuries or significant changes in condition, which was not adhered to in these cases.

Penalty

Inspection fine: $24,668

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, clean, and comfortable environment for a resident, as observed through various deficiencies in room cleanliness. The resident, who had intact cognition and required assistance with transfers and toilet use, was reported by her daughter to have lived in a dirty room. The daughter noted that during visits, her son's feet would become black from the floor, indicating a lack of cleanliness. Upon inspection, the room was found to be unclean even after the resident's discharge, with personal hygiene items left behind, a dried splattered substance on the wall, and a dirty toilet base with dust and a dried brown substance. Additionally, spider webs with spiders were found in the bathroom and window area, and the floor and baseboards were dirty with dust and debris. The Housekeeping Supervisor acknowledged the room's unclean state and attributed the issues to challenges with housekeeping staff availability in June. She admitted to having to perform some housekeeping duties herself due to a staff member's injury. The facility's cleaning policy outlined specific procedures for maintaining cleanliness, including daily trash removal, bathroom cleaning, and weekly dusting and mopping. However, these procedures were not adequately followed, as evidenced by the room's condition. The supervisor recognized the need for changes in the room cleaning policy to prevent such deficiencies in the future.

Penalty

Inspection fine: $24,668

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide Speech Therapy (ST) as ordered by the physician for a resident. The resident, who had a Minimum Data Set (MDS) assessment indicating intact cognition and required partial/moderate assistance with transfers and toilet use, was diagnosed with conditions including hypertension, non-Alzheimer's dementia, depression, parkinsonism, paroxysmal atrial fibrillation, and fibromyalgia. A physician order dated May 21, 2024, directed the facility to provide evaluations and treatments for Physical Therapy (PT), Occupational Therapy (OT), and ST due to Parkinson's disease and falls. Despite the order, the clinical record lacked documentation that the resident received the ST evaluation and treatment. A progress note confirmed that the resident returned from an appointment with new orders for PT, OT, and ST, and the staff was informed of these orders. However, the Regional Nurse Consultant later confirmed that the resident did not receive the ST as ordered. The facility's policy required the charge nurse to record physician orders in the electronic medical record and notify the Primary Care Physician and Power of Attorney if orders were not followed through, which was not documented in this case.

Penalty

Inspection fine: $24,668

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately document a fall and the required assessment related to a fall in the medical record for one resident. This resident, who had intact cognition and required assistance with mobility, experienced an unwitnessed fall in her room. The incident report was incomplete, lacking details such as event specifics, subjective data, environmental factors, pain and body observations, neurological checks, mental status, and interventions. Additionally, the progress notes did not document the fall, nor did they include a fall assessment, neurological assessment, or a fall risk evaluation. For another resident, who also had intact cognition and required assistance with mobility, the facility failed to complete a thorough incident report following an unwitnessed fall. The progress note documented the fall and the resident's injuries, but the incident report was missing critical information, including event details, subjective data, environmental details, pain and body observations, mental status, possible contributing factors, and immediate interventions. A third resident, who was independent with mobility but had a history of syncope and muscle weakness, experienced a fall that was reported by her husband. The incident report for this event was also incomplete, missing sections such as event details, subjective data, environmental factors, pain and body observations, neurological checks, mental status, possible contributing factors, notification guidelines, and interventions. The facility's policy required maintaining medical records within accepted professional standards, which was not adhered to in these cases.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to have a system in place to ensure residents who use Coumadin received their therapeutic monitoring as ordered by the physician. For Resident #13, the facility did not complete the scheduled INR lab draw on time, resulting in an elevated INR level that required holding the medication for two doses. The Director of Nursing (DON) admitted that there was no process in place to ensure INR labs were completed as ordered, and the orders might be lost in a stack of papers on her desk. The Assistant Director of Nursing (ADON) confirmed that the facility only conducted a monthly audit to monitor INR and Coumadin orders, which was insufficient to ensure timely lab draws. Resident #5 missed her lab draw, which led to her missing eight days of Coumadin. An agency nurse failed to enter the lab order into the electronic health record (EHR), causing the lab draw to be missed and the pharmacy to stop sending future warfarin doses. The DON confirmed that the lab was not collected because it did not appear on the lab list, and the facility did not have a follow-up order from the pharmacy. This oversight resulted in Resident #5 having an INR level of 1.02 when it was finally checked. For Resident #16, the facility drew the lab early for their convenience, resulting in a low therapeutic level. The resident had a history of atrial fibrillation, stroke, and long-term use of anticoagulants. The facility did not document subsequent PT/INR lab orders after the initial draw, and the resident's INR level was not monitored as required. The DON and ADON both acknowledged the lack of a proper system to ensure the completion of INR labs, which led to these deficiencies in care.

Removal Plan

• The facility reviewed all 3 residents and ensured each resident received the correct Coumadin dose and completed a lab requisition slip for each resident for their next lab draw.
• The facility developed a new lab order process that involved the use of a lab log and lab requisition order.
• The facility educated the nurses regarding the new processes for lab orders, prothrombin time (PT)/ international normalized ratio (INR) orders tracking and residents on anticoagulants that receive an order for an antibiotic.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow the approved diet menu and accurately measure servings for residents on pureed diets. On 4/3/24, the planned pureed textured diet for lunch included roast turkey, stuffing, chicken gravy, vegetables, bread/margarine, and coffee cream dessert. However, the kitchen staff served tater tot casserole, vegetables, and salad instead. The Dining Services Manager (DSM) prepared the pureed diets by placing unmeasured amounts of tater tot casserole and low-fat milk into a blender, checking the consistency, and adding more milk without measuring. The DSM then poured the mixture into bowls, claiming each bowl contained one serving, and instructed the kitchen server to use a black #4 serving scoop for the vegetables. The kitchen did not have a pureed conversion chart to determine the correct serving size for pureed diets. The facility's policy on pureed diets, dated January 2021, directed staff to measure the desired number of servings before pureeing, add necessary liquids to achieve the correct consistency, measure the volume of the pureed food, and divide the total volume by the original number of portions to determine the new portion size. On 4/9/24, the Chief Clinical Officer confirmed that the pureed preparation should use the volume method involving measuring. The facility's failure to follow the approved diet menu and accurately measure servings for pureed diets was identified through observation, staff interviews, and policy review.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide food served by a method to maintain a safe and appetizing temperature. During a continuous dining observation, a dietary aide took the temperature of two foods, which measured outside the acceptable holding temperature. The pureed tater tot casserole had a temperature of 133.1°F, and the chef salad measured 52.1°F. The dietary aide admitted to not normally checking the temperature of salads and not knowing how to do so. The dining services manager instructed the dietary aide to put the salads in ice to keep them cold, but the salads were served after checking their temperature. Additionally, a staff member prepared a resident plate containing mechanical soft turkey, which measured 129°F, and reheated it to 190°F before serving it to a resident. However, the pureed turkey was served to a resident without rechecking the temperature or reheating it. The facility's Food Preparation and Service policy, revised in October 2018, directed that food held at temperatures between 41°F and 135°F promoted the rapid growth of pathogenic organisms that cause foodborne illness. The policy instructed to maintain the temperature above 135°F. The Food Temperature/Food Safety policy dated March 2024 instructed cooks to measure temperatures before serving food to ensure they maintained below 41°F and above 135°F. If foods were not at the proper temperature, they were to be reheated to 165°F for 15 seconds or cooled to the proper temperature. Cold foods were to be placed in a pan over a deeper pan of ice to keep them at 41°F or below. The Chief Clinical Officer confirmed that staff should follow the food temperature policy.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain sanitary practices in food storage, preparation, and service. Observations revealed that a dietary server placed thumbs on the food surface side of plates before placing them in the serving plate dispenser. Additionally, the kitchen contained unlabeled and undated bags of food, including a bag of red substance, meat chunks, and pasta. The dishwasher, described as a low temp, chemical appliance, failed to show the presence of sanitizer after multiple tests, even after changing the sanitizer supply jug. Maintenance staff indicated that the actuating device might be worn out and needed replacement. Eventually, a sanitizing strip test reflected the presence of sanitizer after multiple attempts. The facility's policies required proper labeling, dating, and sanitizing practices, which were not followed in these instances. Further observations showed cross-contamination during food service. A dietary server placed wax paper on the steam table serving counter, which came into contact with her abdomen. She also handled a steam table pan lid with an ungloved hand, sorted dietary tickets with a gloved hand, and then touched food surfaces with the same hand. The same tongs were used to remove a steam table pan lid and were placed on wax paper that had been contaminated. Additionally, gloves that fell behind a sink faucet were retrieved and used by another staff member to butter bread. The dietary server continued to handle food and utensils improperly, leading to potential contamination. The Chief Clinical Officer confirmed that all food should be labeled and dated, sanitizing regulations should be followed, and dishes should be handled by the edges to prevent contamination.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive water management program and identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. Observations revealed empty soap dispensers in a resident's bathroom and the visitors' main hall men's bathroom, as well as an empty hand sanitizer dispenser between the Assistant Director of Nursing's office and the food serving area. Follow-up observations confirmed that these dispensers remained empty over several days. Staff interviews indicated that the facility was transitioning dispensers and had issues with supply, but there was no clear plan to ensure all rooms had soap dispensers. The Maintenance Supervisor was unaware of the need for soap dispensers in each room and could not access prior water testing results or locate the water management control policy. The third-party company responsible for water testing only checked chlorine levels and did not test for other pathogens on a routine basis. Additionally, the facility lacked a water flow diagram and system measures to identify or prevent the growth of Legionella and other waterborne pathogens. The facility's handwashing policy emphasized the importance of hand hygiene, but the lack of soap and sanitizer dispensers hindered compliance. The undated Water Management Control Policy outlined steps for managing water systems, but these were not implemented effectively. The Chief Clinical Officer confirmed that hand hygiene should occur between glove changes and include soap and water or sanitizer.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the code status between the facility and hospice were congruent for a resident. The resident's clinical records indicated a desire for CPR, as documented by a physician's signed directive. However, the hospice form signed by the resident's Power of Attorney directed no resuscitation, and this form lacked a physician's signature. The discrepancy was noted by nursing staff, who found no signed copy of the Do Not Resuscitate (DNR) form and received conflicting information from the hospice provider and the resident's family. The care plan and physician orders continued to reflect a full code status, while the hospice provider indicated a DNR status. The Assistant Director of Nursing (ADON) acknowledged the inconsistency and mentioned that the facility did not receive the necessary Iowa Physician Orders for Scope of Treatment (IPOST) when the resident returned from the hospital on hospice care. The ADON explained that typically, changes to code status would be made by the Director of Nursing (DON) or other nurses, but there was uncertainty about whether all nurses knew how to update the orders. The facility's policy required that any changes to CPR/DNR designation be documented and signed by a physician, but this was not done in this case. The Regional Director of Quality and Clinical Services confirmed that the facility expected the code status between hospice and the facility to match and that nurses should receive an updated IPOST. The failure to ensure congruent code status between the facility and hospice led to a deficiency in honoring the resident's advance directives and code status preferences.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely family notification when changes occurred in a resident's physical or mental condition. Resident #23, who had severely impaired cognition and required assistance with activities of daily living, experienced a decline in mobility and began using a wheelchair. Despite this significant change, the family was not notified until 2 1/2 to 3 weeks later. The facility's policy required family notification as soon as possible for any significant change of condition, but this was not adhered to in this case. Staff interviews revealed inconsistencies in documentation practices, with one RN stating that family notifications are documented in Progress Notes, but if not documented, it did not necessarily mean the notification was not done. Another RN confirmed that any change in status warrants notification to the family and physician. The Chief Clinical Officer stated that the facility should notify the family within 24 hours of a nonurgent, significant change of condition. However, the documentation showed a delay in notifying the family about Resident #23's mobility decline and need for a wheelchair.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for a resident who was discharged to home. The MDS assessment indicated the resident was discharged on 2/2/24, but the completion date was listed as 4/8/24, and it lacked a signature for the RN verification of completion. The assessment was due on 2/16/24 but was marked as late. The Assistant Director of Nursing acknowledged that the discharge MDS assessment was not completed, and the Administrator reported that the facility did not have a current policy regarding MDS completion, expecting staff to follow the most recent Resident Assessment Instrument (RAI). The Regional Director of Quality and Clinical Services also expected accurate MDS assessments and adherence to the RAI process. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual requires discharge assessments to be completed within 14 days after discharge and transmitted within 14 days of completion.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to invite a resident or the resident's representative to an initial Care Conference. Resident #38, who was admitted on [DATE] and had a BIMS score of 14 indicating intact cognition, reported not being invited to a Care Conference since admission. The clinical record review for Resident #38 lacked documentation of the completion of an initial Care Conference. Interviews with the Regional Director of Quality and Clinical Services and the Assistant Director of Nursing revealed that the quarterly Care Conference for Resident #38 needed to be rescheduled due to the resident's hospital admission. However, there was no awareness or documentation of an initial Care Conference. The facility's policy, effective March 2024, required the preparation of an interdisciplinary person-centered comprehensive Care Plan and the invitation of residents and their representatives to participate in Care Conferences, which was not followed in this case.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service by not having a certified dietary manager. The facility had a census of 34 residents. On 4/1/24 at 9:50 AM, the Dining Services Manager, identified as Staff A, stated she did not have a certification in nutrition and food service management. She mentioned that the facility had a contract dietician who provided monthly dietary service consultation. A course completion certificate reviewed on 4/1/24 at 10:00 AM confirmed that Staff A did not have the required certification. Staff A further stated on 4/3/24 at 7:06 AM that she had no formal training other than a course completed on 9/11/23 and had been working as a dining manager since 12/22/22 without any other dietary management experience. The facility's policy dated September 2019 indicated that the licensed Dietitian along with the facility staff would ensure compliance with State and Federal regulatory requirements.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct annual staff evaluations for five employees, as required by regulation 481-58.20(13). The personnel records of Staff B, Staff C, Staff G, Staff H, and Staff I were reviewed, and it was found that none of these staff members had received an annual evaluation within the required timeframe. Specifically, Staff B's last evaluation was on 7/8/21, Staff C's on 3/4/22, Staff G's on 10/11/21, and Staff I's on 2/17/20. Staff H, who was hired on 3/1/23, had not received any evaluation since their hire date. The facility reported a census of 34 residents at the time of the survey. During interviews, the Administrator admitted that the facility did not have a policy regarding staff evaluations. The Regional Director of Quality and Clinical Services also acknowledged that the facility failed to conduct the evaluations as expected. This lack of compliance with the regulation was identified through personnel record reviews and staff interviews, indicating a systemic issue in the facility's management of staff performance evaluations.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to update a resident's Care Plan following their admission to hospice services. Resident #23, who had a severely impaired cognition with a BIMS score of 7, required setup assistance with eating and moderate assistance with all other ADLs. The resident had diagnoses including coronary artery disease, bipolar disorder, asthma, and depression. Despite being admitted to hospice services on 3/20/24, the Care Plan revised on 3/22/24 did not include hospice services or related interventions, and the EHR lacked hospice Care Plan documents. Interviews and record reviews revealed that the resident's family member confirmed the recent admission to hospice care. A progress note dated 3/21/24 also indicated the resident was under hospice care. The Chief Clinical Officer stated that Care Plans should be revised within 14 days of a significant change. The facility's policy on Comprehensive Care Plans, dated March 2024, indicated that Care Plans should be updated when significant changes occur, but this was not followed in the case of Resident #23.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the required members were present at quarterly Quality Assurance Performance Improvement (QAPI) meetings. Record review revealed that the facility held QAPI meetings on six different dates, but the required members were not present for four of these meetings. Specifically, the Administrator and Medical Director were absent on 2/13/23 and 3/14/23, the Director of Nursing and Administrator were absent on 6/13/23, and the Director of Nursing, Administrator, and Medical Director were all absent on 8/21/23. The facility's QAPI policy, revised in December 2022, mandates the presence of these members to ensure compliance with State and Federal regulations. The Administrator acknowledged the absence of required staff members in the meetings prior to January 2024, and the Regional Director of Quality and Clinical Services confirmed the expectation for the facility to follow QAPI meeting regulations.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate treatment and services to prevent a urinary tract infection (UTI) for a resident with severely impaired cognition and frequent incontinence of bowel and bladder. During an observation, it was noted that the soap dispensers in the resident's bathroom were empty. Staff members were observed performing incontinence care without proper hand hygiene, including rinsing hands with water only and not using soap, and using toilet paper sprayed with cleanser for perineal care. The resident's care plan included a goal to prevent UTIs, but the resident was diagnosed with a UTI and prescribed antibiotics, indicating a failure to meet this goal. Staff interviews revealed a lack of knowledge about the facility's hand hygiene policy, which required handwashing with soap and water after handling soiled items, before and after assisting with toileting, and after removing gloves. The Chief Clinical Officer confirmed that hand hygiene should occur between glove changes and should include soap, water, or sanitizer. The facility's failure to adhere to proper hand hygiene protocols during incontinence care contributed to the resident's UTI, as evidenced by the resident's medical records and staff observations.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to evaluate and manage the use of as-needed (PRN) psychotropic medication within fourteen days for a resident with moderately impaired cognition. The resident, who had diagnoses of Parkinson's disease, dementia, and hallucinations, was prescribed Trazodone for insomnia and restlessness. The medication was administered multiple times over a 28-day period without the required evaluation or documentation from the prescribing practitioner to extend the PRN order beyond the initial 14 days. The facility's policy mandates that PRN orders for psychotropic medications be limited to 14 days unless a clinical rationale for extension is documented by the attending physician or prescribing practitioner. This policy was not followed in the case of the resident, leading to the deficiency noted in the report. The resident's care plan was revised to change the Trazodone order from PRN to a scheduled regimen, and the pharmacist recommended discontinuing the PRN Trazodone. However, the facility did not initially know the resident's administration schedule or duration of Trazodone use prior to admission. The Director of Nursing and the Chief Clinical Officer confirmed that PRN psychotropic medications should be canceled after 14 days or clarified by the provider, which did not occur in this instance. This oversight resulted in the resident receiving the medication beyond the allowed period without proper evaluation or documentation.

Penalty

Inspection fine: $22,481

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure timely completion of Dependent Adult Abuse Mandatory Training recertification for two staff members, a Registered Nurse (RN) and a Maintenance Supervisor. Personnel records revealed that the RN last completed the required 2-hour training on 3/31/21, and the Maintenance Supervisor last completed it on 1/4/21. According to the facility's policy, revised in November 2023, each employee must complete an initial 2-hour training within 6 months of hire and a 1-hour recertification training every three years thereafter. During an interview on 4/9/24, the Regional Director of Quality and Clinical Services acknowledged that both staff members had not completed the recertification training as required by the regulations.