Accura Healthcare Of Carlisle
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlisle, Iowa.
- Location
- 680 Cole Street, Carlisle, Iowa 50047
- CMS Provider Number
- 165255
- Inspections on file
- 32
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Accura Healthcare Of Carlisle during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program, resulting in an ongoing mice infestation affecting resident rooms, staff areas, and common spaces. An LPN reported mice eating food stored in a staff locker, and work orders documented a mouse in a resident room. Surveyors observed mice droppings in multiple drawers of a resident’s clothing dresser and in a vacant room near a heat register. A housekeeping aide reported that mice had chewed and torn stored activity items and that a recliner in a resident’s room contained extensive mice droppings and contaminated soft toys. In the Activity Room, where three residents were present, surveyors observed numerous black and green mice droppings near the entrance and a nightstand, along with debris behind the furniture, despite a facility policy stating it would maintain an effective pest control program for pests and rodents.
A resident with severe cognitive impairment, dependent on staff for personal care and transfers, made repeated statements over two mornings alleging rape by a male individual. Multiple CNAs heard and variably reported these allegations to an RN, but there was confusion about who notified nursing leadership. The DON stated they did not learn of the allegation until the following morning via an LPN, and the abuse report was not submitted to the State Agency until later that morning, exceeding the facility’s policy requirement to report abuse allegations within 2 hours.
A resident reported to a CNA that a male staff member, described by race and role, had raped them and another resident during the night. The CNA informed an RN, who stated they notified the DON that morning, but the DON reported not learning of the allegation until the following day. Review of staffing schedules showed a CNA matching the general description of the alleged perpetrator had worked consecutive night shifts and continued to work and have access to residents after the allegation was first reported to staff. This conflicted with facility policy requiring immediate protective measures, such as suspension or segregation of an employee accused of abuse, upon receipt of an abuse allegation.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
The facility inaccurately completed MDS assessments for several residents by misclassifying antiplatelet medications as anticoagulants and incorrectly coding active diagnoses and PASRR status. These errors were identified through record review and staff interviews, revealing gaps in staff knowledge and documentation practices.
The facility did not develop or implement comprehensive care plans for two residents, one with severe cognitive impairment and dementia, and another with recurrent UTIs. Both residents' care plans lacked focus areas, goals, or interventions for their respective diagnoses, despite documented medical histories and ongoing treatment needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
Staff did not consistently secure and position a resident's catheter bag below the bladder as required by policy and the care plan. The resident, who had a suprapubic catheter and multiple health conditions, was observed with the catheter bag on the floor and above bladder level, and reported difficulty with the catheter while using a wheelchair. The DON confirmed the catheter bag should always be below bladder level.
A resident with diabetes received insulin from an LPN who did not follow manufacturer and facility procedures for insulin pen use. The LPN failed to keep the needle in the skin for the required time after injection, which is necessary to ensure the full dose is delivered. This action did not comply with the physician's orders or the manufacturer's instructions for insulin administration.
Staff failed to properly disinfect a stethoscope and a glucometer after use on two residents, and did not follow glove-changing protocols during care. An LPN placed a used stethoscope on a resident's blanket and over her neck without cleaning it, while an RN inadequately cleaned a glucometer used on multiple residents. These actions did not meet facility infection control policies or manufacturer guidelines.
The facility did not accurately submit direct care staffing data to CMS, as the PBJ report for the specified quarter omitted agency staff who worked on weekends. This omission resulted in the report triggering for excessively low weekend staffing, despite the facility maintaining a census of 70 residents.
A resident with severe cognitive impairment and total dependence for ADLs was observed with chapped, peeling lips despite a physician order for Aquaphor Lip Repair and a care plan for frequent oral hygiene. Documentation showed the lip treatment was not applied for at least 30 days, and staff interviews revealed inconsistent notification to nursing staff about the resident's condition.
Two residents at high risk for pressure ulcers did not consistently receive physician-ordered pressure-relieving devices, such as Prevalon boots and knee wedges, as observed and confirmed by staff interviews and record review. Staff failed to apply these devices as ordered, and there was no documentation of resident refusal or clinical justification for non-compliance, despite clear care plans and facility policy requiring their use.
Two residents with severe mobility and cognitive impairments did not consistently receive their physician-ordered hand splints or palm devices as required to prevent further contractures. Staff failed to apply the DME as ordered, with documentation and observations showing lapses in use and no evidence of resident refusal or medical justification for the omissions.
Staff did not wear required PPE, such as gowns and gloves, while providing direct care to two residents on Enhanced Barrier Precautions for MDRO risk. Despite clear signage and care plans indicating the need for PPE during high-contact activities, CNAs entered rooms and performed care without donning appropriate protective equipment, and staff interviews revealed confusion about EBP requirements.
The facility failed to prevent and treat pressure ulcers for three residents, leading to the development and worsening of Stage 3 ulcers. A resident with Alzheimer's developed a sacral ulcer, but treatment was delayed and supplies were unavailable. Another resident with dementia had a healed ulcer but developed a new one due to inconsistent use of pressure-relieving cushions. A third resident with Alzheimer's developed a gluteal ulcer, with treatment delayed by a week. The facility's lack of timely intervention and documentation contributed to the deterioration of the residents' conditions.
The facility failed to treat residents with dignity and respect, affecting three residents. A resident with paraplegia was hurt during bathing and called 'whiny' by a CNA. Another resident with heart failure was told by the same CNA that she was done helping her. A third resident with diabetes was instructed to urinate in her brief instead of being assisted to the bathroom. These incidents were reported to the DON, but the facility's policy on resident dignity was not followed.
A resident with severe cognitive impairment and anxiety did not receive prescribed lorazepam due to a delay in pharmacy delivery and lack of emergency kit availability. The facility's policy did not address obtaining medications for new orders, leading to the resident experiencing labored breathing and requiring emergency services. The medication arrived as emergency services did, and the resident received her first dose.
A medication cart was found unattended and unlocked in a resident hall, contrary to the facility's policy requiring medication storage to be secured when not attended by authorized staff. An LPN acknowledged the oversight and locked the cart upon returning. The DON confirmed the expectation for staff to lock medication carts when unattended.
The facility failed to secure resident-identifiable information, as observed when a laptop with multiple residents' EHRs was left unattended by an LPN. The facility lacked a policy for securing resident records, and the DON acknowledged the need for staff to ensure information is not displayed when unattended.
The facility failed to implement effective infection control policies, leading to potential cross-contamination risks. Staff were unable to locate necessary sanitizing wipes for cleaning PPE goggles and shared equipment, and improper hand hygiene practices were observed. The absence of sanitizing supplies and adherence to hand hygiene protocols contributed to the deficiencies.
A resident with mental health conditions and incontinence issues was left without timely toileting assistance, leading her to call out for help in the hallway. Despite staff presence, her request was not promptly addressed, violating the facility's dignity policy.
The facility did not maintain the required eight-hour RN coverage on nine days within a month, affecting 71 residents. On six days, there was no RN coverage, and on three days, only four hours of coverage were provided. Staff interviews confirmed the deficiency, with the CNA noting that management could not be counted towards RN coverage, and the Administrator admitting the absence of a policy for eight-hour RN staffing.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses for residents. Observations and interviews revealed significant delays, with some residents waiting up to two hours for assistance. The DON admitted that call light audits had not been conducted for two months, despite the facility's 15-minute response expectation.
The facility failed to implement proper infection control measures, including Enhanced Barrier Precautions (EBP) and PPE usage, for residents at risk of MDRO and those with COVID-19. Staff did not wear gowns during high-contact care for two residents with MDRO risk, and a CNA failed to use eye protection and changed PPE improperly while caring for two COVID-19 positive residents. Interviews confirmed these actions were against facility policy and CDC guidelines.
A resident with moderate cognitive impairment and paraplegia was observed without a dignity cover on their catheter bag on multiple occasions. The resident stated that the cover went missing a long time ago and was not replaced. Staff interviews confirmed that dignity covers should be used, and the DON expected them to be in place, but the facility lacked a specific policy for their use.
The facility inaccurately assessed two residents' statuses in their MDS. One resident was incorrectly documented as having an indwelling catheter, which they never had at the facility, while another resident's use of bed rails was misclassified as a restraint. The DON confirmed these were coding errors, and the facility lacked a specific policy for MDS accuracy.
A facility failed to implement a comprehensive care plan for a resident with moderate cognitive impairment, who required supervision during meals. Despite the care plan's requirement, CNAs left the resident unsupervised during meals while she was in isolation. Staff interviews revealed a lack of awareness about the resident's supervision needs, and the facility lacked a policy on following care plans, leading to the deficiency.
A facility failed to follow procedures for a resident with a PEG tube, who had diagnoses including traumatic brain dysfunction and malnutrition. A physician's order required checking the tube's placement and residual before administering medications. An LPN administered medications without verifying placement or obtaining residual, contrary to the order. The DON confirmed the expectation for these checks, and the facility lacked a policy on enteral feedings.
The facility failed to maintain hot food served at a temperature greater than 140 degrees Fahrenheit during a meal service. Observations and interviews revealed that several food items were below the required threshold, and multiple instances were found where food temperatures were not checked. Residents and staff confirmed that food trays were often served cold, both in resident rooms and dining areas. The facility's Food Temperatures policy was not adhered to, leading to the deficiency.
A resident was not allowed to vape an electronic nicotine device, despite staff being permitted to smoke and two other residents being grandfathered into the facility's no-smoking policy. The resident, who was cognitively intact, felt her rights were violated, and the Volunteer Ombudsman noted inconsistent enforcement of the smoking policy.
The facility failed to follow physician orders for a resident with Diabetes Mellitus, leading to improper administration of Lispro insulin. The resident's blood sugar was checked at 8 a.m., but the insulin was administered at 9:14 a.m., which was not in accordance with the physician's orders. Additionally, Resident Council Meeting Minutes revealed ongoing concerns about the timely administration of medications.
Failure to Maintain Effective Pest Control Resulting in Mice Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free from vermin infestation. Staff interviews revealed an ongoing mice problem in multiple areas, including the staff break room and resident care areas. An LPN reported that mice had eaten a snack stored in her personal locker in the break room about a week prior, and facility work orders documented a mouse in a resident room that was marked as closed. During observations, surveyors found mice droppings in four of six drawers of a resident’s clothing dresser, where socks, jeans, and personal items were stored, and in the corner of a vacant resident room near the heat register. Additional staff interviews and observations showed that the mice problem extended to common and storage areas. The Maintenance Director acknowledged an ongoing mice issue and reported that staff had recently caught live mice in their work area. A housekeeping aide stated that the mice problem was so severe that multiple items in the Activity Room storage closets, including Christmas decorations, were torn and chewed, and staff saw a live mouse jump out of one of the boxes. She also reported that when a recliner cushion in a resident’s room was pulled out, a large amount of mice droppings and some soft toys had to be discarded. During an observation of the Activity Room with three residents present, multiple mice droppings, both black and green, were noted around the room near the entrance door and a nightstand, with debris behind the nightstand. The Administrator confirmed that mice droppings were first noted at the beginning of the month and that the facility had a pest control policy stating it would maintain an effective pest control program for common household pests and rodents.
Failure to Timely Report Resident Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s allegation of sexual abuse to the State Agency within the required 2-hour timeframe. Resident #4, who had severe cognitive impairment with a Brief Interview for Mental Status score of 4 and was dependent on staff for personal care and transfers, made multiple statements over two consecutive mornings alleging rape by a male individual. On the morning of 1/21/26, several CNAs (Staff F, G, and H) reported that Resident #4 stated a black man had raped them, with one CNA documenting that the resident also mentioned a black girl and identified the man as the one who comes in and turns the light on. Staff H’s written statement indicated they informed Staff I, an RN, at approximately 8:00 AM on 1/21/26 of the allegation. Staff I later acknowledged that Staff H reported the allegation to them that morning and stated they then called the DON around 7:30–8:00 AM to report it. Despite these reports, the DON stated they were not contacted on 1/21/26 and first became aware of the allegation the morning of 1/22/26 via a phone call from an LPN. The facility’s Incident Investigative Report showed that the online report of sexual abuse involving Resident #4 was submitted to the Iowa Department of Inspections, Appeals, and Licensing on 1/22/26 at 8:13 AM. Staff interviews revealed confusion and uncertainty among CNAs about who had notified nursing leadership on 1/21/26, with some staff believing others had reported the allegation to a nurse or the DON but unable to confirm this. The facility’s abuse policy, updated 10/19/22, required that allegations of resident abuse be reported to the State Agency no later than 2 hours after the allegation is made, which did not occur in this case.
Failure to Immediately Remove Alleged Perpetrator After Sexual Abuse Allegation
Penalty
Summary
The facility failed to protect residents from further potential abuse after an allegation of sexual abuse was reported. On the morning of 1/21/26, a CNA (Staff H) reported that Resident #4 stated a black man raped me and the black girl when asked how they had slept, and further identified the alleged perpetrator as the man who comes in and turns the light on. After completing personal cares, Staff H informed an RN (Staff I) of the allegation. Staff I acknowledged being approached by Staff H that morning and stated they called the DON at approximately 7:30 AM to report the allegation. However, the DON reported they were not contacted on 1/21/26 and first became aware of the allegation on the morning of 1/22/26. Upon becoming aware of the allegation on 1/22/26, the DON reviewed staffing schedules from the previous day and identified a CNA (Staff J) whose general description matched that provided by Resident #4 and who had worked the night shift on 1/21/26. Staffing schedules showed Staff J worked the night shifts of 1/20/26 and 1/21/26. Staff J was not suspended until 1/22/26, meaning they continued to work and had access to residents after the allegation was initially reported to staff. This sequence of events conflicted with the facility’s written Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, which requires the facility to immediately implement measures to prevent further potential abuse upon receiving an allegation, including suspending or segregating the accused employee or otherwise ensuring no resident contact while an investigation is in process. The facility submitted an online report of the sexual abuse allegation involving Resident #4 to the state agency on 1/22/26 at 8:13 AM.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Inaccurate MDS Assessments Due to Medication and Diagnosis Coding Errors
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for four out of twenty-three residents reviewed. Specifically, the MDS assessments incorrectly documented that certain residents were taking anticoagulant medications when, according to the electronic health records and physician orders, they were actually prescribed antiplatelet medications such as Clopidogrel (Plavix), which should not be classified as anticoagulants. Additionally, there were inaccuracies in coding active diagnoses, such as viral hepatitis, and in documenting PASRR (Pre-admission Screening and Resident Review) status for residents with mental health diagnoses. These errors were identified through clinical record review, staff interviews, and comparison with the Resident Assessment Instrument (RAI) Manual guidelines. The MDS Coordinator, who had been in the role since December, reported using the RAI Manual, staff input, and a medication classification list to complete assessments but demonstrated a lack of understanding regarding the correct classification of medications and the criteria for coding active diagnoses. For example, the coordinator incorrectly coded antiplatelet medications as anticoagulants and was uncertain about the look-back period for active diagnoses such as viral hepatitis. The facility's documentation practices did not align with the requirements outlined in the RAI Manual, leading to inaccurate MDS assessments for multiple residents with complex medical histories, including those with coronary artery disease, cerebrovascular accident, quadriplegia, and mental health conditions.
Failure to Develop Comprehensive Care Plans for Residents with Dementia and Recurrent UTIs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two out of five residents reviewed. For one resident with severe cognitive impairment and a diagnosis of non-Alzheimer's dementia, the care plan did not include any focus area, goals, or interventions related to the dementia diagnosis, despite this being documented in the resident's Minimum Data Set (MDS). For another resident with a documented history of recurrent urinary tract infections (UTIs), the care plan similarly lacked any focus area, goals, or interventions addressing the UTI diagnosis, even though the resident had multiple recent episodes of UTIs treated with antibiotics and this condition was noted by the physician. Clinical record reviews, staff interviews, and policy review confirmed these omissions. The Director of Nursing acknowledged that care plans are expected to accurately reflect residents' health conditions, including specific diagnoses and related interventions. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs, but this standard was not met for the residents in question.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established plan or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Properly Position Catheter Bag Below Bladder Level
Penalty
Summary
Staff failed to properly secure and position a resident's catheter bag below the level of the bladder, as required by facility policy and the resident's care plan. The resident, who had a history of renal insufficiency, obstructive uropathy, diabetes, and a suprapubic catheter, was observed on multiple occasions with the catheter bag either lying on the floor under the wheelchair or hung above the level of the bladder. These observations were made during routine checks and included instances where the catheter bag contained yellow urine and was not properly secured, as well as when the resident reported difficulty accessing the call light due to running over the catheter tubing with the wheelchair. Further review of the clinical record and staff interviews confirmed that the facility's policy required the catheter bag to be kept below the level of the bladder at all times to ensure proper drainage and minimize infection risk. The Director of Nursing acknowledged that the catheter bag should be positioned below the bladder. The care plan for the resident specifically directed staff to maintain this positioning, but staff failed to consistently follow these instructions, as evidenced by the surveyor's observations.
Insulin Administration Not Performed per Manufacturer and Physician Instructions
Penalty
Summary
A deficiency occurred when staff failed to administer insulin according to both physician's orders and manufacturer instructions for a resident with diabetes and diabetic neuropathy. During a medication pass, an LPN used a new Novolog insulin flexpen, labeled and dated it, attached a needle, and primed the pen by dialing to 2 units and expelling insulin. The LPN then set the pen to 3 units, donned gloves, and injected the insulin into the resident's abdomen. However, the LPN removed the needle from the injection site within 1-2 seconds, rather than following the required procedure to keep the needle in the skin for at least 6 seconds to ensure the full dose was administered. Facility competency guidelines and manufacturer instructions both specify that after pressing the injection button, the needle should remain in the skin for a specified period to ensure the complete dose is delivered. The LPN did not adhere to this step, potentially resulting in an incomplete dose. The DON confirmed the correct procedure for insulin pen use, including the importance of priming and ensuring the full dose is administered, but the observed practice did not align with these standards.
Failure to Disinfect Resident Care Devices and Follow Infection Control Practices
Penalty
Summary
Facility staff failed to properly disinfect resident care devices and adhere to infection control practices as observed during routine care of two residents. In one instance, a resident with a history of pneumonia, on antibiotics, and receiving tube feeding via a gastrostomy tube was attended by an LPN who donned appropriate personal protective equipment but placed a used stethoscope on the resident's blanket and later draped it over her neck without disinfecting it. The LPN also handled trash and opened the resident's door with gloved hands, then continued care activities without changing gloves as required. The care plan for this resident indicated the need for enhanced barrier precautions due to the risk of multidrug-resistant organisms (MDRO) related to the indwelling tube. In another instance, an RN checked a resident's blood sugar and cleaned the glucometer with an alcohol swab for less than five seconds before storing it, despite the device being used on multiple residents. Facility policy and manufacturer instructions required the use of a specific disinfectant wipe with a two-minute wet contact time for proper disinfection. Interviews with the Director of Nursing confirmed expectations for staff to follow these infection control protocols, which were not met in these observed cases.
Failure to Accurately Report Weekend Staffing in PBJ Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for the Payroll Based Journal (PBJ) Staffing Data Report covering January 1st to March 31st, 2025. The PBJ report triggered for excessively low weekend staffing during this period. Upon review, it was determined that the facility's PBJ data submission did not include staffing agency staff who worked on weekends, despite the facility maintaining a census of 70 residents. The Administrator confirmed in an interview that the omission of agency staff led to the inaccurate reporting, and the Regional Director later submitted a PBJ report that did not reflect concerns, but the original deficiency remained due to the incomplete data submission.
Failure to Provide Ordered Lip Care and Oral Hygiene Assistance
Penalty
Summary
A resident with severe cognitive impairment, quadriplegia, and total dependence for all activities of daily living was observed with chapped and peeling lips while reclined in a Geri chair. The resident had a physician order for Aquaphor Lip Repair to be applied as needed for dry, chapped lips, and the care plan included oral hygiene assistance every two hours while awake. Despite these interventions, the Medication Administration Records for the previous 30 days showed no documentation that Aquaphor had been applied. Staff interviews revealed that CNAs were responsible for checking the resident's lips during oral hygiene and notifying the nurse if chapped lips were observed, but there was uncertainty among staff regarding notification requirements. The resident's brother had previously expressed concerns about the resident's dry, chapped lips, and a progress note indicated some improvement at one point, but no further documentation was available regarding ongoing treatment. On the day of observation, the resident's lips remained chapped and peeling, and the assigned nurse was not notified of the condition. The facility did not have a specific policy for activities of daily living, and the Director of Nursing confirmed that staff should have notified the nurse to apply Aquaphor.
Failure to Provide Ordered Pressure Ulcer Prevention Devices
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention and care for two residents who were at high risk for developing pressure ulcers. For one resident with severe cognitive impairment, quadriplegia, and protein-calorie malnutrition, physician orders and the care plan required the use of Prevalon boots at all times except during transfers. However, observations showed the resident was repeatedly without the prescribed boots while seated in a Geri chair in the television area, and the boots were found stored in the resident's room instead of being worn. Staff interviews confirmed that the boots were not applied as ordered, and there was no documentation of resident refusal or any clinical justification for not following the order. Another resident, who had Alzheimer's disease, joint contracture, and a history of a Stage 3 sacral pressure ulcer, also had physician orders for Prevalon boots and a knee wedge to be used at all times except during transfers. Observations revealed this resident was in the dining room and later in bed without the required pressure-relieving devices in place. Staff expressed uncertainty about when the devices should be used, and the care plan and task lists did not provide clear or consistent guidance. There was no documentation of resident refusal or any reason for not using the devices as ordered. Both residents were identified as high risk for pressure ulcers according to their Braden Scale assessments, and their care plans and treatment records reflected the need for pressure-reducing interventions. Despite this, staff failed to consistently implement physician-ordered interventions, and documentation did not reflect any refusals or clinical reasons for non-compliance. Facility policy required interventions to be implemented according to physician orders, but this was not followed in these cases.
Failure to Consistently Apply Ordered DME for Residents with Limited ROM
Penalty
Summary
The facility failed to ensure that ordered Durable Medical Equipment (DME) was used as prescribed to prevent further decline in range-of-motion (ROM) for two residents with significant mobility impairments. In the first case, a resident with severe cognitive impairment, quadriplegia, and a history of stroke was observed multiple times without the required palm DME, despite a physician's order for it to be worn at all times except for pain, hygiene, or skin checks. Documentation in the electronic health record and treatment administration record indicated inconsistent application of the DME, and staff interviews confirmed lapses in following the order, with one CNA admitting to forgetting to apply the device after transporting the resident. In the second case, another resident with Alzheimer's disease, joint contracture, and severe communication limitations was observed without her bilateral hand splints, which were ordered to be worn every shift with removal allowed for two hours per day. Review of the electronic health record showed minimal documentation of splint or brace assistance over the previous 30 days, and the treatment administration record indicated the order was in place. Staff interviews revealed that the splints had been removed for a shower and were not reapplied within the prescribed timeframe, exceeding the allowed period without the splints. Both residents were dependent on staff for all activities of daily living and had documented bilateral ROM impairments. The facility's own restorative program process required licensed nurses to monitor compliance with restorative interventions, but observations and documentation revealed that staff did not consistently apply or monitor the use of prescribed DME, and there was no documentation of resident refusal or medical justification for the lapses.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to don appropriate Personal Protective Equipment (PPE) when providing direct care to two residents who were on Enhanced Barrier Precautions (EBP). Observations showed that multiple Certified Nurse Aides (CNAs) entered the rooms of these residents without wearing gloves or gowns, despite clear signage on the doors indicating the need for such precautions during high-contact activities such as dressing, bathing, transferring, changing linens, providing hygiene, and device or wound care. The EBP orders and care plans for both residents specifically directed the use of these precautions due to their risk of multidrug-resistant organism (MDRO) colonization or infection. Interviews with staff revealed a lack of understanding regarding the requirements of EBP, with some CNAs unsure about when to use gowns and gloves or which resident the precautions applied to. Both residents involved had significant medical conditions, including quadriplegia, pressure ulcers, feeding tubes, and severe cognitive impairment, making them highly dependent on staff for all activities of daily living. The facility's policy on EBP, updated prior to the incidents, clearly outlined the need for targeted gown and glove use during high-contact care, but this was not followed during the observed care activities.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for three residents. Resident #1, who had Alzheimer's and severe cognitive impairment, developed a new Stage 3 pressure ulcer on her sacrum. Despite the identification of the ulcer, there was a delay in implementing a treatment plan, and the necessary wound care supplies were not available in a timely manner. The resident's wound deteriorated, and there was a lack of documentation for the implementation of prescribed treatments and the use of a pressure-relieving cushion. Resident #3, who had dementia and depression, was identified with a Stage 3 pressure ulcer on the right buttock. The facility's records indicated that the ulcer was initially healed, but a new ulcer developed. There was inconsistency in the use of pressure-relieving cushions, and the facility failed to ensure the resident had the appropriate cushion in her chair, which may have contributed to the development of the new ulcer. Resident #4, who had Alzheimer's disease and severe cognitive impairment, developed a new Stage 3 pressure ulcer in the left gluteal cleft. The facility did not start treatment for the ulcer until a week after it was identified, and there was a lack of documentation regarding the implementation of the treatment plan. The facility's failure to promptly address and document the treatment of pressure ulcers contributed to the worsening of the residents' conditions.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that staff treated residents with dignity and respect, affecting three residents. Resident #2, who has paraplegia, anxiety, and depression, reported that a CNA accidentally hurt her arm during bathing and called her 'whiny' when she expressed pain. The resident's cognitive status was intact, as indicated by a BIMS score of 15 out of 15. Another incident involved Resident #7, who has heart failure, depression, and a psychotic disorder, and was reported to have been told by the same CNA that she was done helping her, although the CNA later returned to assist the resident. Resident #7 had a BIMS score of 9, indicating moderately impaired cognition. Resident #8, who has diabetes, Parkinson's, and anxiety, reported that a CNA instructed her to urinate in her brief instead of assisting her to the bathroom. This resident also had intact cognition with a BIMS score of 15. Staff interviews revealed that these incidents were reported to the Director of Nursing, although the DON stated she was not informed about the incident involving Resident #8. The facility's policy on promoting and maintaining resident dignity was not adhered to, as evidenced by these interactions.
Failure to Administer Prescribed Medication Due to Pharmacy Delay
Penalty
Summary
The facility failed to administer a prescribed medication intervention for a resident with severe cognitive impairment and multiple diagnoses, including hemiplegia, diabetes, and anxiety. The resident had a physician's order for lorazepam to be administered every six hours for anxiety/agitation. However, the medication was not administered as scheduled on two occasions because it had not been delivered by the pharmacy and was not available in the facility's emergency kit. This resulted in the resident experiencing labored breathing, prompting the family to request emergency medical services. The facility's policy on medication ordering and receiving did not provide guidance on obtaining medications for new orders, contributing to the delay in administration. The Director of Nursing indicated that the facility followed standards of care but acknowledged that nurses should special order medications and contact the pharmacy for delivery times if there were delays. The medication was eventually delivered at the same time emergency services arrived, and the resident received her first dose of lorazepam.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to properly secure medications from unauthorized access, as observed with an unattended and unlocked medication cart in a resident hall. This incident occurred when a Licensed Practical Nurse (LPN) exited a resident's room and returned to find the medication cart unlocked. The LPN then locked the cart and acknowledged that it should not have been left unlocked. The facility's policy, revised in November 2018, mandates that medication rooms, carts, and supplies must be locked when not attended by authorized personnel. The Director of Nursing (DON) confirmed that staff are expected to ensure medication carts are locked if they are leaving them unattended.
Failure to Secure Resident Information
Penalty
Summary
The facility failed to protect resident-identifiable information, as observed during a survey. On January 13, 2025, a laptop was found open with a resident's Electronic Health Record (EHR) visible, unattended by any staff. A Licensed Practical Nurse (LPN) later accessed the laptop, revealing EHR information for 16 residents, and then left the laptop unattended again. On January 14, 2025, another observation noted a laptop with a resident's EHR visible, which was later secured by another staff member. The facility lacked a policy for securing resident records, as confirmed by the Administrator, and the Director of Nursing (DON) acknowledged that staff should ensure resident information is not displayed when unattended.
Infection Control Deficiencies Due to Lack of Sanitizing Supplies and Poor Hand Hygiene
Penalty
Summary
The facility failed to implement effective infection control policies, leading to potential cross-contamination risks. On multiple occasions, staff were unable to locate purple-top sanitizing wipes (saniwipes) necessary for cleaning Personal Protective Equipment (PPE) goggles and shared equipment like the EZ Stand used for resident transfers. Staff D, E, and F confirmed the absence of saniwipes, which were supposed to be used for cleaning goggles after use in Covid+ resident rooms. Observations revealed that PPE bins contained goggles but lacked saniwipes, and a used earloop mask was improperly stored on a PPE bin. Staff G admitted to the shortage of saniwipes since a vendor change, and the Administrator acknowledged the supply issue. Additionally, Spectrum Advanced hand sanitizing wipes, not suitable for cleaning medical equipment, were found in place of the required saniwipes. Further deficiencies were noted in hand hygiene practices. Staff K, a Certified Med Aide, was observed handling multiple residents' utensils without performing hand hygiene between interactions. This was contrary to the facility's hand hygiene policy, which mandates hand hygiene after touching a resident or their environment. The Director of Nursing confirmed that staff should perform hand hygiene between residents and use saniwipes on shared equipment, highlighting a gap between policy and practice. The facility's failure to ensure the availability of appropriate cleaning supplies and adherence to hand hygiene protocols contributed to the infection control deficiencies.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to uphold the dignity of a resident by not providing an alternative method for obtaining toileting assistance. This deficiency was observed when a resident, who was rarely or never understood due to her mental status, was left without timely assistance for incontinence care. The resident, diagnosed with Chronic Kidney Disease, paranoid Schizophrenia, and PTSD, required moderate assistance for most Activities of Daily Living and was occasionally incontinent of urine and frequently incontinent of stool. On the morning of the incident, the resident was observed asking for help to be changed, but was instructed to follow her normal method of contacting staff, which was ineffective at that time. The resident, unable to receive timely assistance, walked to the main corridor and called out for help. Despite the presence of staff members in the vicinity, the resident's request was not immediately addressed until a CNA arrived and inquired if she wanted to go to breakfast, at which point the resident reiterated her need to be changed. The facility's policy on promoting and maintaining resident dignity requires staff to respond to requests for assistance promptly, yet the resident's care plan lacked specific directives for incontinence care, contributing to the delay in addressing her needs.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for eight consecutive hours on nine out of thirty-two days reviewed between July 28th and August 28th, 2024. The facility, which reported a census of 71 residents, lacked RN coverage entirely on six specific days and only had four hours of RN coverage on three additional days. Interviews with staff, including a Certified Nurse Aide (CNA) and the Administrator, confirmed the absence of adequate RN coverage. The CNA noted that management could not be counted towards the required RN coverage, and the Administrator acknowledged the lack of a policy for ensuring eight-hour RN staffing, despite following regulations.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Observations and interviews revealed that residents experienced significant delays in call light responses, with some waiting up to two hours. Resident #35, with no cognitive impairment, reported waiting over 30 minutes for assistance while in the bathroom, ultimately performing peri care and transferring herself back to her wheelchair. Resident #38, also cognitively intact, noted delays of 15 to 30 minutes, corroborated by a resident council meeting where attendees consistently complained about prolonged response times. Further investigation showed that Resident #2, with moderate cognitive impairment and dependent on staff for toileting and dressing, experienced call light delays of nearly two hours. Resident #41, with intact cognition and using a walker, reported waits often exceeding 30 minutes. Continuous observation in Hall 200 confirmed a call light remained unanswered for 20 minutes, as noted by a family member. The Director of Nursing acknowledged that call light audits had not been conducted for two months due to staffing changes, despite the facility's expectation of a 15-minute response time.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) for two residents at risk for Multi-Drug Resistant Organisms (MDRO). Resident #2, with a diagnosis of paraplegia and chronic obstructive pulmonary disease, had a physician's order for EBP due to the risk of MDRO related to a catheter and wound. However, during an observation, a Certified Nursing Assistant (CNA) did not wear a gown while performing catheter care, contrary to the care plan and facility policy. Similarly, Resident #7, diagnosed with traumatic brain dysfunction and other conditions, had a physician's order for EBP, but staff failed to don gowns during enteral feeding and incontinence care, as observed on multiple occasions. The facility also failed to properly use personal protective equipment (PPE) for two residents with a positive COVID-19 diagnosis. Resident #49 and Resident #60, both with moderate cognitive impairment, were in isolation due to their COVID-19 status. During an observation, a CNA donned a gown, gloves, and mask but failed to wear eye protection while supervising a meal for Resident #60. The CNA then proceeded to move between rooms and the shower room without changing PPE, which is against the expected protocol for transmission-based precautions. Interviews with staff, including the Director of Nursing (DON), confirmed that the expectation was for gowns to be worn during high-contact care activities and for eye protection to be used when required by transmission-based precautions. The facility's policy on Enhanced Barrier Precautions, updated in May 2024, aligns with the Centers for Disease Control and Prevention (CDC) guidelines, which emphasize the importance of PPE in preventing the spread of MDROs and other infections. However, the observations and staff interviews indicate a failure to adhere to these guidelines, leading to the deficiencies noted in the report.
Failure to Provide Dignity Cover for Catheter Bag
Penalty
Summary
The facility failed to uphold the dignity of a resident by not providing a privacy cover for a catheter bag. Resident #2, who has moderate cognitive impairment, paraplegia, and chronic obstructive pulmonary disease, was observed on two separate occasions without a dignity cover on their urinary drainage bag. The resident reported that the facility never covers the drainage bag and that the cover went missing a long time ago. Interviews with staff, including a CNA and CMA, confirmed that urinary drainage bags should have dignity covers. The Director of Nursing expressed that her expectation was for dignity bags to be used, while the Administrator noted that the facility does not have a specific policy for dignity bags, instead following general standards of care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess and document the status of two residents, leading to discrepancies in their Minimum Data Set (MDS) assessments. For Resident #38, the MDS inaccurately documented the presence of an indwelling catheter, despite the resident stating they had not used a catheter in about two years and had never had one at the facility. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) also showed no physician's order for a catheter, and the resident's care plan did not include any mention of an indwelling catheter. The Director of Nursing (DON) confirmed that this was a coding mistake and that the resident had never had a catheter while at the facility. For Resident #2, the MDS indicated the use of bed rails daily, classifying them as a restraint, despite an assessment in the Electronic Health Record stating that the bed rails were used for positioning purposes. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The DON acknowledged the expectation for MDS assessments to be completed and coded correctly. Additionally, it was noted that the facility lacked a specific policy for ensuring MDS accuracy, relying instead on general regulatory compliance.
Failure to Implement Comprehensive Care Plan for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with moderate cognitive impairment, as documented in the Minimum Data Set (MDS). The care plan specified that the resident could eat independently in the dining room with supervision after setup. However, during observations, staff members left the resident unsupervised during meals while she was in isolation due to COVID-19. On two separate occasions, Certified Nursing Assistants (CNAs) delivered the resident's meal tray, set it up, and left the room without providing the required supervision. Staff interviews revealed that the CNAs were unaware of the resident's supervision needs during meals. The Director of Nursing (DON) acknowledged that the resident's care plan required supervision during meals, especially during isolation. Additionally, the facility lacked a policy on following care plans, which was considered a standard of care. This oversight led to the resident being left unsupervised during meals, contrary to her documented care plan requirements.
Failure to Verify PEG Tube Placement and Residual
Penalty
Summary
The facility failed to implement policies and procedures regarding the technical aspect of feeding tubes, specifically for Resident #7, who has a diagnosis of traumatic brain dysfunction, pneumonia, malnutrition, and artificial openings of the gastrointestinal tract. The physician's orders for Resident #7 required checking the placement and residual of the Percutaneous Endoscopic Gastrostomy (PEG) tube before administering medications. However, during an observation, a Licensed Practical Nurse (LPN) accessed the resident's PEG tube and administered a flush and medications without verifying the tube's placement or obtaining residual. The LPN later acknowledged that a residual check should have been completed. The Director of Nursing (DON) confirmed that the expectation is for residual checks and placement verification to be completed as ordered. Additionally, the facility lacked a policy related to enteral feedings for review.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain hot food served at a temperature greater than 140 degrees Fahrenheit during a meal service. Observations and interviews revealed that the temperatures of several food items were below the required threshold, including taco casserole at 135 degrees, rice at 137 degrees, and mashed potatoes at 120 degrees. Staff A, the cook, confirmed that the mashed potatoes were not placed on the steam table properly, which contributed to the low temperature. The facility's Steamtable Temperature logs showed multiple instances where food temperatures were not checked for various meals throughout April 2024. Staff B, the Dietary Manager, confirmed that the logs were not completed thoroughly as per facility policy. Interviews with residents and staff further corroborated the issue of cold food being served. Resident #1 and several CNAs/CMA staff members confirmed that food trays were often served cold, both in resident rooms and dining areas. The Resident Council Meeting Minutes also documented complaints about food being served cold or burnt and dry meat. The facility's Food Temperatures policy from 2021 stated that all hot food items must be cooked, held, and served at a temperature of at least 135 degrees Fahrenheit, and temperatures should be periodically checked to ensure compliance. However, the facility failed to adhere to this policy, leading to the deficiency.
Failure to Treat Resident with Dignity and Respect Regarding Smoking Policy
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not allowing her to vape an electronic nicotine device, despite staff members being permitted to smoke and two other residents being grandfathered into the facility's no-smoking policy. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed discontent during an interview, stating that she felt her rights were violated. The resident had signed an Admission Agreement identifying the facility as a non-smoking campus, but she claimed she was not of sound mind at the time due to taking Methadone, which affected her ability to make clear decisions. The Volunteer Ombudsman also voiced concerns about the facility's inconsistent enforcement of its smoking policy, noting that staff members were observed smoking in both designated and non-designated areas. The facility's smoking policy, as outlined in the Admission Agreement and Employee Handbook, prohibits smoking and vaping on the property. However, the policy allowed staff to smoke in designated areas during breaks, which contributed to the resident's perception of unfair treatment. The facility's failure to uniformly enforce its smoking policy and to consider the resident's preference to vape led to the deficiency in treating the resident with dignity and respect.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for a resident with Diabetes Mellitus, leading to improper administration of Lispro insulin. The Medication Administration Record (MAR) indicated that the resident should receive 3 units of Lispro insulin subcutaneously with meals and to hold if blood sugars were less than 90. Additionally, a sliding scale of Lispro insulin was to be administered based on blood sugar levels. On the observed date, a Licensed Practical Nurse (LPN) administered 3 units of scheduled Lispro insulin along with 2 units of sliding scale Lispro insulin to the resident's left arm after the resident had already eaten breakfast. The blood sugar was checked at 8 a.m. and recorded as 172, but the insulin was administered at 9:14 a.m., which was not in accordance with the physician's orders. The Nurse Practitioner confirmed that this was not the correct procedure for administering the insulin. The Resident Council Meeting Minutes also revealed ongoing concerns about the timely administration of medications. Specifically, residents reported that night medications were not passed on time and that medications were not administered on time on multiple occasions. These concerns were documented in the meeting minutes from January and February. This indicates a pattern of issues related to medication administration within the facility, contributing to the deficiency identified by the surveyors.
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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