Accura Healthcare Of Ames, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Ames, Iowa.
- Location
- 3440 Grand Avenue, Ames, Iowa 50010
- CMS Provider Number
- 165423
- Inspections on file
- 24
- Latest survey
- March 27, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Accura Healthcare Of Ames, Llc during CMS and state inspections, most recent first.
A resident with newly identified mental health diagnoses and related medication orders did not receive a timely Level II PASRR evaluation. The facility lacked a specific protocol for submitting PASRRs, resulting in a delay in the required screening process after the resident's mental health status changed.
A resident with physical dependencies and a history of muscular dystrophy, PTSD, and burns was allowed to use and store a vape pen in his room without proper assessment or supervision. Staff were inconsistently aware of the resident's vaping, and the required smoking evaluation and care plan were not completed, contrary to facility policy prohibiting smoking or vaping inside and mandating secure storage of such materials.
Three residents with indwelling urinary catheters were observed with catheter tubing in contact with the floor or other unclean surfaces, despite care plans directing proper catheter maintenance and monitoring. Staff and leadership acknowledged lapses in following protocol and the absence of a specific catheter care policy, while residents experienced complications including UTIs and required medical intervention.
Surveyors found that food items in the kitchen were left uncovered and lacked proper labeling and dating, including drinks, salads, and unidentified meat. Staff also brought in items that were not labeled or dated, and the ice scoop was stored unsanitarily on top of the ice machine instead of in a container, contrary to facility policy.
The facility submitted inaccurate staffing data to CMS by misclassifying staff roles in the PBJ system, including CNAs coded as CMAs and administrative staff coded as direct care staff. These errors occurred on multiple occasions, leading to incorrect reporting of staffing levels, especially on weekends. Leadership interviews confirmed expectations for accurate clock-ins and schedule matching, but discrepancies persisted despite established review processes.
A facility failed to provide adequate supervision, resulting in injuries to two residents. One resident, requiring assistance with personal hygiene, was left unattended in the bathroom and fell, sustaining a hip fracture. Another resident, with severe cognitive impairment, was sent to a dental appointment without staff accompaniment, fell, and suffered a dental fracture. Both incidents highlight a lack of adherence to care plans and supervision protocols.
The facility failed to provide adequate supervision during medication administration for three residents. A resident with mild cognitive impairment was left unattended with medications, while another resident's medical information was left visible on a computer screen. Additionally, a glass of water containing medication was left unsupervised at a dining table. The Director of Nursing acknowledged the lack of a specific policy on leaving medications unattended.
The facility failed to maintain safe and appetizing temperatures for food served to residents. A cook checked the temperature of 13 menu items, all above 135°F, but the first tray on the delivery cart had broccoli at 99.0°F, tater tots at 127.9°F, and milk at 44.7°F. Remaining food on the steam table was also below the required temperature. The facility's policy required hot foods to be at least 135°F and cold foods below 41°F. The administrator acknowledged the need to discard the food and prepare a new plate.
The facility failed to maintain sanitary practices in food storage and preparation, with undated and unlabeled food items found in refrigerators and freezers. Staff members were observed not using required hairnets and beard coverings in the food preparation area, violating the facility's policies on food safety and sanitation.
A facility failed to refer a resident for a Level II PASARR evaluation despite the resident's diagnosed serious mental disorder and use of psychotropic medications. The resident had moderate cognitive impairment and was diagnosed with various mental health conditions, including personality disorders and PTSD. The facility did not update the PASARR after new diagnoses were added, and lacked a policy for regular PASARR audits.
A facility failed to maintain a safe environment by leaving a medication cart unlocked and unsupervised. A CMA left the cart unattended while administering medications to a resident, with the cart positioned out of sight. The DON acknowledged the lack of a policy requiring staff to lock medication carts when not in sight, expecting adherence to professional standards.
The facility failed to provide the correct protein portion size for three residents on pureed diets. Staff A prepared a pureed mixture and served only one #8 scoop of protein instead of the required two, resulting in half the necessary portion size being served. The Administrator confirmed that staff should follow the pureed conversion chart, which was not adhered to during meal service.
The facility failed to maintain proper infection control practices in two incidents. A CMA prepared medication for a resident without performing hand hygiene after coughing and blowing her nose. Additionally, a cook placed a resident's blanket in a shared sink, compromising sanitation. The resident had severely impaired vision and required assistance with personal hygiene. The DON confirmed these actions were against the facility's guidelines.
The facility failed to maintain confidentiality during medication administration for two residents. A CMA left a glass of water with Miralax unattended at a dining table, and an RN did not secure a computer screen displaying a resident's information. The DON acknowledged the lack of a policy for securing computer screens.
Failure to Submit Timely Level II PASRR Evaluation for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to submit a Level II Preadmission Screening and Resident Review (PASRR) evaluation for a resident who developed new mental health diagnoses after admission. Clinical record review showed that the resident had multiple mental health diagnoses, including delusional disorder, adjustment disorder with mixed anxiety and depressed mood, anxiety disorder, and depression, with corresponding medication orders for antipsychotic, antianxiety, and antidepressant medications. The resident's care plan identified behavioral concerns and interventions related to impulsivity and excessive use of the call light. Despite these new diagnoses and medication changes, the facility did not initiate a Level II PASRR evaluation until several months after the resident's mental health conditions were documented. The initial PASRR Level I screen indicated no mental health diagnosis at admission, with instructions to submit a new screening if changes occurred. Staff interviews confirmed that there was no specific policy or protocol in place for timely completion of PASRRs, and the process for the Level II evaluation only began after the deficiency was identified.
Failure to Assess and Supervise Resident Vaping in Room
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not properly assessing and supervising a resident who used a vape pen in his room. The resident, who had intact cognition but was dependent on staff for bathing, toileting, and transfers, and used a wheelchair for mobility, was not included on the facility's list of smokers and did not have a completed smoking evaluation in his clinical record. Despite signing an admission checklist indicating receipt and understanding of the facility's smoking policy, the resident reported using a vape pen in his room, keeping it on his person, and charging it himself. He stated he was unaware that vaping in his room was prohibited and was unsure if staff knew about his vaping habits. Staff interviews revealed inconsistent awareness and enforcement of the facility's smoking policy. A CNA stated that residents were required to vape outside with supervision and could not keep vaping supplies in their rooms, but was unaware that the resident vaped. An RN had seen the vape pen in the resident's room and assumed he vaped there, but did not report this to administration. The administrator was unaware of the resident's vaping and stated that staff were expected to report such incidents. The facility's smoking policy explicitly prohibited smoking or vaping inside the facility, required storage of all smoking materials by staff, and mandated smoking evaluations and care plan interventions for residents who smoke or vape. These procedures were not followed for the resident in question, resulting in a failure to prevent potential accident hazards.
Failure to Prevent Catheter-Associated UTIs Due to Improper Catheter Care
Penalty
Summary
The facility failed to provide appropriate interventions to minimize or prevent urinary tract infections (UTIs) for three residents with indwelling urinary catheters. For one resident with moderate cognitive impairment and a history of urinary retention, kidney disease, and previous UTIs, observations revealed that her catheter tubing was in direct contact with the carpeted floor before entering the collection bag. Her care plan included monitoring for signs of infection and ensuring proper catheter maintenance, but these interventions were not effectively implemented. Another resident with intact cognition and a diagnosis of neurogenic bladder was observed with her catheter tubing touching the floor tiles before entering the collection bag. Despite care plan instructions to monitor for catheter complications and change the bag as ordered, the resident experienced a period of no urinary output after receiving IV fluids, requiring catheter repositioning and flushing. She was subsequently treated for a UTI with antibiotics. A third resident with benign prostatic hyperplasia and urinary retention was repeatedly observed with his catheter tubing touching both outdoor patio cement and indoor carpeted floors while his catheter bag hung from his walker. Staff, including the DON and ADON, acknowledged that catheter tubing should not touch the floor and recognized the need for improved staff education and interventions. The facility did not have a specific policy on urinary catheters, and staff interviews confirmed awareness of UTI trends and the need for additional measures related to catheter care and placement.
Failure to Properly Label, Date, and Store Food and Utensils
Penalty
Summary
Surveyors observed multiple instances of improper food storage and handling in the facility's kitchen, including uncovered food items in refrigerators and freezers, such as drinks in adaptive plastic cups and various salads in bowls and plates. Food packages were found without labels to identify the product, open date, or use by date, including unidentified meat in a plastic zip lock bag and several bagged items in the freezer. Additionally, staff brought in several items in a grocery bag that were not dated or labeled. The ice scoop for the ice machine was observed stored on top of the machine without a container, rather than in a sanitary container as required. The facility's policy directed that all leftover food should be covered, labeled, and dated before refrigeration, but these procedures were not followed.
Inaccurate PBJ Staffing Data Submission Due to Coding Errors
Penalty
Summary
The facility failed to submit accurate staffing data to the CMS Payroll Based Journal (PBJ) system for the reporting period of October 1, 2024, to December 31, 2024. A review of daily assignment sheets and staff punch detail reports revealed multiple coding errors, including instances where Certified Nursing Assistants (CNAs) were incorrectly coded as Certified Medication Aides (CMAs), Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) were coded as CMAs, and administrative staff such as the MDS Coordinator and Assistant Director of Nursing (ADON) were coded as direct care staff for shifts they worked. These inaccuracies were found on numerous dates throughout the reporting period, affecting the accuracy of the facility's reported staffing levels, particularly on weekends. Interviews with facility leadership confirmed that staff working dual roles were expected to clock in under the correct job duty, and that the Office Manager and ADON were responsible for ensuring daily schedules matched employee punches. Despite these expectations, the errors persisted, and the facility's process involved a corporate staff member completing the PBJ submission after facility review. The facility's policy required timely and accurate PBJ submissions, but the observed discrepancies indicated a failure to meet this standard.
Failure to Provide Adequate Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, who required assistance with personal hygiene and ambulation. On the morning of July 4, 2024, Staff A, a Certified Nursing Assistant (CNA), assisted Resident #1 to the bathroom with a walker but left the resident unattended. As a result, Resident #1 lost balance and fell, sustaining a left hip fracture. The resident had a history of moderate cognitive impairment and required substantial assistance with activities of daily living, including toileting and ambulation. The care plan indicated the need for one-person assistance, which was not adhered to, leading to the fall. In a separate incident, Resident #2, who had severe cognitive impairment and a history of falls, was transported to a dental appointment without staff assistance. During the appointment, Resident #2 fell and sustained a dental fracture. The care plan for Resident #2 specified that a staff member or family should accompany the resident to appointments, but this was not followed, resulting in the fall and subsequent injury. Both incidents highlight a failure in the facility's supervision and adherence to care plans, which are critical for ensuring resident safety. The lack of staff presence during personal care tasks and appointments for residents with cognitive impairments and mobility issues directly contributed to the accidents and injuries sustained by the residents.
Inadequate Supervision During Medication Administration
Penalty
Summary
The facility failed to provide adequate supervision during medication administration for three residents. Resident #31, with mild cognitive impairment and a history of medically complex conditions, was left unattended with her medications on a tray table while she was in the bathroom. Staff E, a Certified Medical Assistant, left the medications in the room without ensuring Resident #31 took them, despite the facility's policy requiring staff to watch residents consume their medication. Additionally, Resident #31's roommate had a history of suicidal behavior, which further emphasized the need for supervision. In another instance, Staff G, a Registered Nurse, left a blood glucose monitor, lancets, and insulin pens unattended in Resident #46's room after performing a glucose test. This occurred while Resident #46 and her roommate were present. Furthermore, Staff G failed to close the computer screen, leaving Resident #46's information visible. Similarly, Staff F, a Certified Medication Aide, left a glass of water containing Miralax unattended at a dining table for Resident #19, without supervising her consumption. The Director of Nursing acknowledged the lack of a specific policy on leaving medications unattended but expected staff to follow professional standards of care.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain safe and appetizing temperatures for food served to residents. On May 21, 2024, a cook checked the temperature of 13 menu items on the steam table, all of which were above 135°F. However, when the first tray was placed on the delivery cart, the temperature of the broccoli was 99.0°F, the tater tots were 127.9°F, and the milk was 44.7°F. Later, the remaining food on the steam table was found to have temperatures of 117.2°F for chicken soup and 130.1°F for tomato soup. The facility's policy from 2021 required hot foods to be held and served at a minimum of 135°F and cold foods to remain below 41°F during the holding and plating process. The administrator acknowledged that the food should have been discarded and a new plate prepared for the resident.
Sanitary Practices and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary practices in food storage and preparation, as observed during a survey. Multiple refrigerators and freezers contained undated and unlabeled food items, including drinks, beef paste, strawberries, cheese, and other unidentified items. Additionally, the ice machine scoop was improperly stored without a barrier. These practices were not in accordance with the facility's Food Storage policy, which requires all refrigerated and frozen foods to be covered, labeled, and dated. Furthermore, staff members were observed not adhering to the facility's Food Safety and Sanitation policy, which mandates the use of hair restraints and beard nets. A Dietary Aide and a Maintenance Assistant were seen in the food preparation area without proper hairnets or beard coverings. Additionally, a Cook was observed handling food without following proper sanitary procedures. These actions were contrary to the facility's policies, which require thorough cleaning and sanitization of utensils and serving dishes prior to use.
Failure to Update PASARR for Resident with Serious Mental Disorder
Penalty
Summary
The facility failed to refer a resident with a Level I Preadmission Screening and Resident Review (PASARR) for a Level II evaluation despite the presence of a diagnosed serious mental disorder. The resident, identified as having moderate cognitive impairment, was diagnosed with several mental health conditions, including specific personality disorders, anxiety disorder, vascular dementia, and PTSD. The resident was also on antipsychotic and antidepressant medications. Despite these diagnoses and treatments, the facility did not update the PASARR to reflect the need for a Level II evaluation when new diagnoses were added. The resident's clinical record showed that the Level I PASARR completed in November did not require a Level II evaluation, as it documented no serious mental impairment at that time. However, subsequent diagnoses of specific personality disorders were added, and the resident was prescribed additional psychotropic medications. The facility lacked a policy for PASARR updates and did not conduct regular audits to ensure compliance with federal regulations. The administrator acknowledged the oversight and provided a new Level I PASARR during the interview, but the deficiency remained unaddressed at the time of the survey.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to maintain a safe environment by leaving a medication cart unlocked and unsupervised. During an observation, a Certified Medication Aide (CMA) left the medication cart unlocked and unattended while administering medications to a resident. The cart was positioned against the wall outside the resident's room and was out of sight from the room. In an interview, the Director of Nursing (DON) acknowledged the absence of a facility policy requiring staff to lock medication carts when not in sight. The DON expected staff to adhere to professional standards of care, which include keeping the medication cart locked at all times when away from it or when it is not visible.
Failure to Serve Correct Protein Portion Size for Pureed Diets
Penalty
Summary
The facility failed to serve the correct serving size of protein for three out of five residents who were on pureed diets. During an observation, Staff A prepared a pureed mixture of pork casserole, pineapple sauce, and bread, which was then measured to yield five cups. According to the pureed portion conversion chart, the required serving size was two #8 scoops, equating to 8 ounces. However, Staff A only served one #8 scoop of protein per plate, providing half of the required portion size. An observation at the end of the meal service showed that more than half of the pureed protein remained uneaten. The facility's Administrator confirmed that staff should adhere to the pureed conversion chart during meal service. The facility's Puree Process document directed staff to use the correct scoop size corresponding to the portion size, but this was not followed.
Infection Control Lapses in Medication Preparation and Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices, as observed in two separate incidents involving residents. In the first incident, a Certified Medication Aide (CMA) was observed preparing medication for a resident after coughing into her hands and blowing her nose without performing hand hygiene. This action was contrary to the facility's expectations, as stated by the Director of Nursing (DON), who emphasized the importance of hand hygiene before and after each medication pass, especially after coughing or blowing one's nose. In the second incident, a cook placed a resident's blanket in a shared sink while delivering a lunch tray, which was not in line with maintaining a sanitary environment. The resident involved had a history of severely impaired vision and required assistance with personal hygiene. The blanket was later observed back on the resident's legs and lying on the floor. The DON confirmed that the blanket should not have been placed in the sink, as per the facility's general guidelines policy, which directed staff to maintain a sanitary environment.
Confidentiality Breach During Medication Administration
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records during medication administration for two of the five residents reviewed. On May 20, 2024, a Certified Medication Aide left a glass of water containing Miralax unattended at a dining table for a resident, without supervising her consumption, in the presence of other residents. Additionally, a Registered Nurse conducted a blood glucose test and administered insulin to another resident but failed to secure the computer screen displaying the resident's information, leaving it visible to others. The Director of Nursing acknowledged the absence of a policy to ensure the computer screen's security when unattended and expected staff to adhere to professional standards of care.
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 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.
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.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
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.
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.
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.
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 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.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
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.
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.
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