Accura Healthcare Of Carroll
Inspection history, citations, penalties and survey trends for this long-term care facility in Carroll, Iowa.
- Location
- 2241 North West Street, Carroll, Iowa 51401
- CMS Provider Number
- 165455
- Inspections on file
- 22
- Latest survey
- December 23, 2025
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Accura Healthcare Of Carroll during CMS and state inspections, most recent first.
Multiple residents who were dependent on staff for daily care experienced significant delays in call light response, with documented wait times frequently exceeding the expected 15-minute standard, especially on weekends. Residents with complex medical needs reported waiting up to 39 minutes for assistance, and the facility lacked a formal call light policy, relying instead on state standards.
Multiple residents with complex medical conditions reported that call lights frequently took longer than 15 minutes to be answered, especially during evenings, weekends, and mornings. Facility records confirmed response times up to 39 minutes, and the DON acknowledged the issue, noting the absence of a formal call light policy and inconsistent adherence to the expected 15-minute response time.
A resident with multiple chronic conditions experienced a fall during a transfer when the care plan was not updated to reflect a change from two-person to one-person assist, as recommended by physical therapy. Staff interviews confirmed that only one staff member was assisting during transfers, and the DON acknowledged the care plan was outdated. The facility's policy required timely care plan revisions, but this was not followed.
Several residents, including those with cognitive impairment and those with intact cognition, experienced care that did not promote dignity or respect. Staff were observed or reported to have acted aggressively, used dismissive or rude language, rushed through care, and failed to respond promptly to requests for assistance, resulting in residents feeling neglected, demeaned, or discouraged from seeking help.
A CNA did not receive required dependent adult abuse recertification training within the mandated three-year period, as facility tracking incorrectly scheduled the training after the certificate's expiration. The DON confirmed staff are expected to complete DAA training before expiration.
A resident with dementia and multiple comorbidities received PRN antipsychotic and antianxiety medications for periods exceeding regulatory limits without required physician assessments, clinical rationales, or documentation of behavioral symptoms and nonpharmacological interventions prior to administration. Facility policy and federal guidelines for psychotropic medication use were not followed, as confirmed by review of clinical records and staff interviews.
A resident was subjected to repeated physical actions by a CNA during a meal, which was witnessed by an RN. The RN delayed reporting the incident to management, and the facility subsequently failed to notify the state agency within the required 2-hour window, as mandated by policy. Staff interviews indicated confusion about reporting timelines, contributing to the deficiency.
A staff member accused of abuse was not promptly separated from a resident and other residents after an incident was witnessed by an RN. The RN delayed reporting the allegation to management, resulting in the staff member continuing to work her shift and interact with residents for several hours before being suspended, contrary to facility policy requiring immediate separation upon receiving abuse allegations.
A resident with multiple serious health conditions received an antidepressant medication in error for nearly two weeks due to a nurse confusing two hospice patients with similar initials. The same resident also missed several doses of a prescribed fentanyl patch for pain management because the medication was out of stock and a nurse entered a verbal order to hold the patch without direct physician communication. Staff interviews revealed confusion in the medication ordering process, and the facility lacked a specific policy for medication errors.
A resident with significant risk factors for skin breakdown developed a Stage III pressure ulcer after staff failed to implement and document necessary repositioning interventions. Despite being dependent on staff for mobility and having a care plan that identified skin integrity risks, the resident was not placed on a turning schedule, and staff did not consistently reposition the resident as required. Observations confirmed prolonged periods without repositioning, contributing to the development of the pressure ulcer.
A resident with multiple complex medical conditions, including a stage 4 pressure ulcer, experienced severe unplanned weight loss due to the facility's failure to conduct timely weight monitoring, nutritional assessments, and interventions. Despite policy requirements for regular and post-hospitalization weights, staff did not obtain weights as required, delayed reweighs after significant loss, and failed to notify the RD or physician in a timely manner, resulting in a lack of appropriate response to the resident's declining nutritional status.
The facility did not accurately complete MDS assessments for several residents, failing to document PASRR Level II status, oxygen therapy, CPAP use, and hospice care as required. Staff interviews revealed that only partial PASRR information was reviewed, and there was no facility policy guiding MDS completion, resulting in assessments that did not reflect residents' actual clinical status or services received.
Staff failed to follow posted menus and serve correct portions for residents on pureed and mechanical soft diets, resulting in inappropriate substitutions such as pudding instead of pureed cake and serving poppyseed cake and chopped lettuce to those with dietary restrictions. The dietary manager did not measure pureed food portions, leading to inconsistent servings, and both the dietary manager and dietitian were unfamiliar with proper procedures for therapeutic diets.
Staff failed to consistently use proper sanitation practices during food storage, preparation, and service, including not wearing hairnets, improper glove use, and handling food with gloved hands instead of utensils. The refrigerator for resident food items was visibly soiled, lacked temperature monitoring, and had no cleaning logs, with unclear staff responsibility for its upkeep.
Three CNAs did not complete the required 12 hours of annual in-service training due to a lack of tracking and access to the facility's education system. The facility's own assessment called for ongoing training and needs assessments, but these were not fulfilled for the CNAs reviewed.
The facility did not provide clear or complete information about room and board charges to several residents, with admission agreements missing specific rates or containing only notations instead of amounts. In one instance, a resident was not notified in writing of a rate increase, despite facility policy requiring such notification. Facility leadership acknowledged that rates should have been properly documented and communicated.
Two residents were found to be living in rooms with spider webs, stained and soiled bathroom walls and floors, missing grout, and black substances present. Family and staff interviews confirmed that these cleanliness and maintenance issues were not reported or addressed as required by facility procedures.
A resident with severe cognitive impairment and multiple diagnoses developed blisters suspected to be shingles, leading to a new order for antiviral medication. The facility did not notify the resident's family about the new medication or the suspected infection, and staff confirmed that no documentation of family notification was present.
A resident was discharged from the facility, but the required discharge MDS assessment was not set up or completed within the federally mandated timeframe. The MDS Coordinator indicated that such assessments are usually initiated on the day of discharge and checked by the social worker, but could not explain how this omission occurred. The Nurse Consultant noted that the facility lacks a specific policy for MDS completion and relies on RAI guidelines.
A resident with multiple skin impairments did not receive consistent wound care and assessments as ordered, including incomplete documentation of weekly skin checks, lack of follow-up on dietary supplement recommendations, and application of treatments not specified in physician orders. Staff interviews confirmed that required assessments and communications were not performed according to facility policy.
A resident with multiple medical conditions and a history of falls was assisted by a CNA during a transfer, became weak, and was lowered to the floor, sustaining an abrasion. After the incident, staff did not complete a root cause analysis, update the care plan with new fall interventions, or perform required follow-up assessments and vital sign checks, as required by facility policy. Staff interviews revealed inconsistent use of gait belts and incomplete documentation and investigation of the event.
Three residents with cardiac and respiratory conditions did not receive physician-ordered respiratory care, including cases where oxygen cannulas were disconnected, portable oxygen tanks were empty, and oxygen was administered at incorrect flow rates. Staff failed to monitor, document, and follow orders, and the facility lacked a policy for ensuring compliance with respiratory care protocols.
A registered nurse did not wear a gown while administering tube feedings and water flushes to a resident with a feeding tube, despite facility policy requiring Enhanced Barrier Precautions for residents with indwelling medical devices. The resident was totally dependent on staff and had recently returned from the hospital with aspiration pneumonia.
A facility failed to implement an effective pest control program, resulting in a bed bug infestation in the rooms of two residents. Staff were uncertain about the steps to take, and the facility lacked a specific policy for dealing with such infestations. One resident, with moderate cognitive deficit, was moved to a different room, while another resident, who was independent, passed away shortly after the incident. The pest control company confirmed the presence of bed bugs, but the facility's response was inadequate due to the absence of a detailed policy and staff education.
The facility failed to store, prepare, serve, and distribute food in accordance with professional standards. Staff members inconsistently practiced hand hygiene during meal preparation, and the resident unit refrigerator was improperly maintained, lacking a temperature log and containing outdated items.
The facility failed to refer a resident with severe cognitive impairment and new diagnoses of dementia and bipolar disorder for a Level II PASRR evaluation. Staff acknowledged the oversight and stated that a new PASRR should have been completed, but the facility lacked a specific PASRR policy.
A resident with severe cognitive impairment and diagnoses of Alzheimer's, anxiety, and depression had a PRN order for lorazepam without a specified stop date. The medication was administered multiple times over several months without physician review. The DON acknowledged the oversight and stated the facility lacked a policy for reviewing PRN psychotropic medications.
The facility failed to obtain bed hold notifications for four residents who were transferred to the hospital or on therapeutic leave. The DON acknowledged the oversight, believing social services were responsible. The facility's policy requires written notice for hospital transfers, which was not followed.
Delayed Call Light Response for Dependent Residents
Penalty
Summary
The facility failed to provide timely responses to call lights for four residents who were dependent on staff for various activities of daily living, including toileting hygiene, showering, dressing, transfers, and mobility. Clinical record reviews, facility document reviews, and interviews with both staff and residents revealed that call light response times frequently exceeded the facility's expected standard of 15 minutes, particularly on weekends. Documented call light logs showed multiple instances where residents waited between 17 and 39 minutes for assistance, with several occurrences of wait times over 30 minutes. Residents reported that delays were especially pronounced on weekends, and some expressed frustration with the length of time it took to receive help. The residents involved had significant medical conditions such as diabetes, heart failure, chronic obstructive lung disease, stroke, and dementia, and were largely dependent on staff for their care needs. Despite the presence of monitors displaying active call lights and their durations, the facility did not have a formal call light policy in place, instead relying on a state standard for response times. The deficiency was identified through a combination of resident interviews, review of call light logs, and staff interviews, all of which confirmed the pattern of delayed responses to resident needs.
Delayed Call Light Response Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to resident call lights, as evidenced by multiple resident interviews and review of call light response logs. Several residents, all with varying degrees of cognitive function and complex medical histories including heart failure, diabetes mellitus, hyperlipidemia, morbid obesity, arthritis, hip fracture, and mental health disorders, reported that call lights often took longer than 15 minutes to be answered, particularly during evenings, weekends, and morning shifts. These delays were corroborated by facility documentation showing response times ranging from 16 to 39 minutes on multiple occasions. The Director of Nursing acknowledged that call light response times were an ongoing issue and provided logs confirming extended delays. Additionally, the DON stated that the facility did not have a formal call light policy and instead relied on general standards of care. The expectation communicated by the DON was for call lights to be answered within 15 minutes, but this standard was not consistently met, as shown by both resident reports and facility records.
Failure to Revise and Implement Accurate Care Plan for Resident Transfer Needs
Penalty
Summary
The facility failed to revise and implement an accurate care plan for one resident following changes in the resident's transfer needs. The resident, who had diagnoses including heart failure, renal insufficiency, diabetes mellitus, hyperlipidemia, and morbid obesity, was initially care planned for transfers with assistance from two staff members using a walker and gait belt. However, after being discharged from physical therapy, the resident's transfer status had improved to require only one staff member with a gait belt and walker. Despite this change, the care plan was not updated to reflect the new level of assistance needed. On the day of the incident, the resident experienced muscle jerks and dizziness while preparing to transfer from the bed to a wheelchair. The CNA assisting the resident followed the resident's preference for the gait belt placement and attempted to readjust the belt when the resident reported nausea. During this process, the resident became anxious, stood up, and fell forward onto the floor. Multiple staff responded, assessed the resident, and used a mechanical lift to transfer the resident to a wheelchair. The resident initially complained of toe pain, and later reported ankle pain, prompting a transfer to the hospital for further evaluation. Interviews with staff confirmed that the resident was being assisted by only one staff member during transfers, consistent with the updated physical therapy recommendations but inconsistent with the care plan documentation, which still indicated assistance from two staff members. The Director of Nursing acknowledged that the care plan was not correct and should have been updated to reflect the resident's current needs. Facility policy required care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment, but this was not done in this case.
Failure to Promote Resident Dignity and Respect
Penalty
Summary
The facility failed to provide care that promoted dignity and respect for six out of fifteen residents reviewed. Multiple staff, including CNAs, were observed or reported to have interacted with residents in a manner that was dismissive, rough, or disrespectful. For example, one resident with severe cognitive impairment and total dependence for eating was observed by an RN to have his hands swatted away multiple times by a CNA when reaching for his food, with the CNA becoming increasingly aggressive and eventually shoving the resident's wheelchair away from the table. Another resident with intact cognition reported that a CNA's attitude made her feel like a bother when asking for help, discouraging her from seeking assistance. Other residents described similar negative experiences. One resident reported that a CNA rushed through care, left the room while the resident was speaking, and delayed responding to call lights, resulting in the resident having an accident and feeling terrible. Another resident stated that a CNA was rude, rough, and left her on the toilet for 20 minutes, which she felt ruined her dignity. Additional reports included complaints of negative attitudes, rushing through care, and not providing requested assistance such as water or help off the toilet. A resident with moderately impaired cognition reported being called a derogatory name by staff after spilling food and described staff as having a short and rude tone. Hospice staff corroborated concerns about staff demeanor and responsiveness, noting that suggestions to improve the resident's mood and care were dismissed due to staffing issues. Facility policy requires staff to treat residents with respect and dignity, but the documented actions and attitudes of certain staff members did not align with these expectations, resulting in a failure to maintain or enhance residents' quality of life.
Failure to Provide Timely Dependent Adult Abuse Recertification Training
Penalty
Summary
The facility failed to provide dependent adult abuse (DAA) recertification training within the required three-year period for one of two employees reviewed. Personnel file review showed that a CNA was hired on 5/15/24 and had last completed the mandatory 2-hour DAA training on 5/8/22. According to facility policy, staff are required to complete a 1-hour recertification within three years of the initial training and every three years thereafter. Staff interviews revealed that the CNA did not have an updated DAA certificate as of the time of review, and the facility's tracking system had incorrectly marked the training as due in May 2025, rather than before the three-year expiration. The DON confirmed the expectation that staff complete DAA training prior to certificate expiration.
Failure to Limit and Document PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to comply with federal regulations regarding the use of PRN (as needed) psychotropic medications, specifically antipsychotics and antianxiety drugs, for a resident with multiple complex medical conditions, including Alzheimer's disease, anxiety disorder, and depression. The clinical record review revealed that PRN antipsychotic medications such as Haloperidol and Zyprexa were ordered and administered for periods exceeding the 14-day federal limit without documented physician assessments or clinical rationales for the extended use. Orders for these medications were repeatedly renewed for 30 days or longer, and pharmacy consulting reports consistently recommended reassessment and adherence to the 14-day limitation, but these recommendations were not followed with appropriate documentation or evaluation by the prescribing physician or practitioner. Additionally, the facility failed to document behavioral symptoms or the use of nonpharmacological interventions prior to administering PRN antianxiety medications, such as Ativan, as required by both facility policy and federal regulation. The medication administration records showed frequent use of these medications over several months, yet there was a lack of corresponding documentation of behaviors or attempts at alternative interventions before medication was given. The Director of Nursing confirmed that staff were expected to document behaviors and nonpharmacological interventions prior to administering PRN psychotropic medications, but this was not consistently done. The facility's own policy required that PRN orders for psychotropic medications be limited to 14 days unless a clinical rationale for extension was documented, and that nonpharmacological approaches be attempted first. Despite this, the clinical records lacked evidence of physician assessments, clinical rationales for extended PRN use, and documentation of behavioral monitoring or nonpharmacological interventions. These failures were observed for one resident reviewed for unnecessary medications, in a facility with a census of 47 residents.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required 2-hour timeframe to the Iowa Department of Inspections, Appeals and Licensing (DIAL). According to facility documentation, a Certified Nursing Assistant (CNA) was observed by a Registered Nurse (RN) pushing a resident's hands away from his plate multiple times during breakfast and eventually wheeling the resident away from the table before he finished his meal. The RN reported the incident to the Administrator at approximately 3:30 PM, several hours after the event occurred. The facility then contacted the State Agency by phone at 4:57 PM and completed the online self-report the following morning. Staff interviews revealed that the RN believed abuse allegations without observable injury needed to be reported within 24 hours, rather than the required 2 hours. The Director of Nursing (DON) stated that staff are expected to report abuse immediately and separate the resident from the alleged abuser. Facility policy, updated in October 2022, clearly states that all allegations of resident abuse must be reported to the state agency within 2 hours. The delay in reporting the incident constituted a failure to follow both regulatory requirements and facility policy.
Failure to Timely Separate Staff Accused of Abuse from Residents
Penalty
Summary
The facility failed to promptly separate a staff member accused of abuse from dependent residents following an incident involving a resident during breakfast. According to documentation, a Certified Nursing Assistant (CNA) was observed by a Registered Nurse (RN) repeatedly pushing a resident's hands away from his plate and eventually shoving his wheelchair away from the table before he finished his meal. The RN did not immediately report the incident to management, waiting until approximately 3:30 PM to notify the Administrator, despite the incident occurring at 7:30 AM. As a result, the accused CNA continued to work her shift and had contact with residents, including the resident involved in the alleged abuse, until she was suspended later that afternoon. Facility records, including time card data and staff interviews, confirmed that the CNA remained on duty from early morning until late afternoon, only being separated from residents after the allegation was reported to management. The facility's policy requires immediate action to prevent further potential abuse by separating the accused employee from residents upon receiving an allegation. However, this protocol was not followed, as the delay in reporting and subsequent action allowed the staff member to continue working with residents for several hours after the alleged incident.
Significant Medication Errors in Medication Administration and Ordering
Penalty
Summary
A significant medication error occurred when a nurse entered a prescription for fluoxetine for a resident who was not intended to receive it. The error happened because the nurse confused two hospice residents with similar initials while processing physician orders. As a result, the resident received 24 doses of fluoxetine over nearly two weeks before the mistake was discovered. The resident's family was notified after the error was identified, and the nurse acknowledged the mistake during an interview. Additionally, the same resident did not receive a prescribed fentanyl patch for pain management as ordered. The medication was out of stock, and the patch was not applied for several days. Documentation shows that the pharmacy was awaiting provider approval for the refill, and a verbal order to hold the patch was entered by a nurse without direct communication with the physician. The resident's family and ARNP were updated about the situation, and progress notes indicated that the resident went without the patch during this period. Interviews with staff revealed inconsistencies in the medication ordering and reordering process, including uncertainty about whether the patches had been reordered and a lack of clarity regarding the use of the emergency kit. The facility did not have a specific policy related to medication errors, instead relying on standards of practice. The resident involved had multiple complex medical conditions, including cancer, hypertension, peripheral vascular disease, COPD, malnutrition, depression, and chronic pain, and was receiving hospice services at the time of the deficiencies.
Failure to Prevent Pressure Ulcer Development Due to Lack of Repositioning Interventions
Penalty
Summary
A deficiency occurred when a resident, who was at risk for pressure ulcers due to multiple medical conditions including Type 2 diabetes with foot ulcer, peripheral vascular disease, cerebrovascular accident with hemiplegia, and requiring substantial assistance for bed mobility, developed a Stage III pressure ulcer. The resident's care plan identified risks related to skin integrity and ADL deficits but failed to document the need for turning or repositioning to prevent pressure ulcers, nor did it specify the assistance required for bed mobility. The Minimum Data Set (MDS) also indicated the resident was not on a turning/repositioning program and lacked nutrition or hydration interventions for skin management. Observations and staff interviews revealed that the resident spent significant time in a recliner, which became saturated with urine due to a clogged catheter, and was not using her bed. The facility's skin management protocol and care documentation did not include specific interventions such as regular repositioning. Staff reported that the resident was dependent on them for repositioning, but continuous observation showed that repositioning was not performed at the recommended frequency. The resident was observed to remain in the same position for extended periods, and staff did not consistently provide repositioning care, even when prompted by the nurse consultant. Wound assessments documented the development and progression of a Stage III pressure ulcer on the resident's right buttock, with moderate exudate and macerated wound edges. The facility's policy did not specify repositioning interventions, and staff interviews confirmed that repositioning was not routinely provided. The lack of timely and appropriate interventions to prevent pressure ulcer development directly resulted in harm to the resident.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to conduct appropriate weight monitoring, nutritional assessments, interventions, and timely physician/family notifications for a resident who experienced severe unplanned weight loss. The resident had multiple complex medical conditions, including anemia, diabetes mellitus, paraplegia, depression, cirrhosis, chronic kidney disease, and a stage 4 pressure ulcer. Despite being on a therapeutic diet and receiving several nutritional supplements, the resident experienced a significant weight loss of over 12% in a short period, with weights dropping from 274 lbs to 230.6 lbs over approximately two months. Documentation revealed that after a hospitalization for dehydration and norovirus, the resident was not weighed upon return to the facility, and weekly weights were not initiated as would be expected for a resident with wounds and recent acute illness. The registered dietician (RD) and nursing staff failed to obtain timely reweighs when significant weight loss was identified, and there was a lack of communication and follow-up between dietary and nursing regarding the resident's nutritional status. The RD requested a reweigh after noting a 35 lb weight loss in six weeks, but the reweigh was not completed until 12 days later, and the RD was not notified of the result. No further dietary assessments, interventions, or physician/family notifications were documented after the additional weight loss was identified. The facility's policy required residents to be weighed on admission, daily for three days, then weekly for three weeks, and then monthly unless otherwise ordered. The policy also required reweighs and physician notification for weight changes of three or more pounds. However, these protocols were not followed for this resident, as evidenced by the lack of timely weights, reweighs, and notifications. Staff interviews confirmed that there was confusion regarding the frequency of weights and that the facility did not have a specific policy addressing significant weight loss. The failure to follow established protocols and ensure timely assessment and intervention contributed to the resident's severe unplanned weight loss.
Inaccurate MDS Assessments Due to Incomplete PASRR and Service Documentation
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for 7 out of 13 reviewed residents, as identified through clinical record review, staff interviews, and reference to the 2024 Resident Assessment Instrument (RAI) Manual. Specific deficiencies included not properly documenting PASRR Level II status and related conditions for several residents who had been identified by the state process as having serious mental illness, intellectual disability, or related conditions. In multiple cases, the MDS did not reflect the PASRR findings, with required questions either marked incorrectly or left blank, despite clear instructions in the PASRR documentation and the RAI Manual. Additionally, the MDS failed to document the use of oxygen therapy, CPAP, and hospice care for residents who had active orders or were receiving these services according to their electronic health records. Interviews with facility staff revealed that the MDS Coordinator only reviewed the first page of the PASRR forms and did not follow the instructions on subsequent pages, leading to incomplete or inaccurate MDS entries. The Nurse Consultant confirmed that the facility did not have a specific policy for MDS completion and relied solely on the RAI guidelines. These actions and omissions resulted in the MDS assessments not accurately reflecting the residents' clinical status and required services, as mandated by federal assessment protocols.
Failure to Follow Therapeutic Diet Menus and Portion Requirements
Penalty
Summary
The facility failed to follow the posted menus and serve appropriate portions and therapeutic diets to residents requiring pureed and mechanical soft diets. Specifically, two residents on pureed diets did not receive the correct dessert as outlined in the menu spreadsheet, with one receiving pudding instead of the required pureed orange cake without poppyseeds. Additionally, six residents on mechanical soft diets were served items not suitable for their dietary needs, such as poppyseed cake and chopped lettuce, instead of the specified alternatives like orange cake without poppyseeds and shredded lettuce. Observations during meal service revealed that the Certified Dietary Manager (CDM) did not measure food portions after pureeing, resulting in inconsistent serving sizes. The CDM was unaware that the addition of liquid during pureeing could alter the final volume, leading to residents receiving less than the required portions. Furthermore, the CDM admitted to not reading the menu spreadsheet and consistently serving inappropriate items to residents on special diets during multiple menu rotations. The Registered Dietitian also indicated unfamiliarity with the correct method for measuring pureed food portions and confirmed that residents on mechanical soft diets should not have received poppyseeds or chopped lettuce. The failure to adhere to the prescribed menus and dietary modifications resulted in residents not receiving meals that met their nutritional needs and physician-ordered therapeutic diets.
Failure to Maintain Food Sanitation and Safe Handling Practices
Penalty
Summary
The facility failed to maintain proper food sanitation and safety practices during food storage, preparation, and service. During a kitchen walkthrough, it was observed that the refrigerator designated for resident food items brought in by families was visibly soiled, lacked thermometers, and had no cleaning or temperature logs. Staff interviews revealed uncertainty regarding responsibility for monitoring and cleaning this refrigerator, and it was acknowledged that it had not been cleaned for an extended period. During lunch service, multiple staff members, including the dishwasher and Certified Dietary Manager (CDM), were observed not wearing required hairnets, and this was not corrected by other staff present. The CDM, while preparing pureed food, used gloved hands to handle food items and, at one point, used her gloved finger to wipe food off a spatula into a steam pan. Another staff member used gloved hands to manipulate baked potatoes during meal plating, despite having access to utensils. These actions were inconsistent with both facility policy and FDA Food Code requirements, which specify the use of utensils and proper glove use to prevent contamination. Additionally, two Certified Nurse Aides entered the kitchen without hairnets to obtain leftover food, and only after being observed were they reminded to wear hairnets. Staff interviews confirmed that expectations for glove use, utensil use, and hair restraint were not consistently followed or enforced. The lack of clear assignment for refrigerator monitoring and cleaning, combined with observed lapses in food handling and personal hygiene practices, contributed to the deficiency.
Failure to Ensure Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) completed the required 12 hours of annual in-service training, as evidenced by personnel record review and staff interviews. Three CNAs, all hired within the past two years, did not have documentation of completed continuing education. The Nurse Manager reported that the previous Business Manager had not been tracking CNA education in the Relias system, and one CNA had not been given access to Relias at all. The facility's own assessment indicated that ongoing training and an educational needs assessment were part of their staff training program, but these requirements were not met for the CNAs reviewed.
Failure to Provide Complete Room Rate Information to Residents
Penalty
Summary
The facility failed to provide complete and accurate information regarding room rates to residents at the time of admission and when rate changes occurred. For four residents reviewed, admission agreements either lacked the specific daily room and board charges or contained incomplete information, such as leaving the rate line blank or filling it in with non-numerical notations like 'SNF' or 'MCD.' In one case, a resident's agreement listed a base rate, but there was no documentation that the resident was notified in writing of a subsequent rate increase, as required by facility policy. Interviews with facility leadership confirmed that the room and board rates should have been clearly documented and communicated to residents or their representatives.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for two of three residents reviewed. A family member reported concerns about the cleanliness of a resident's room, specifically noting spider webs in the corners and dirty floors. Observations confirmed the presence of spider webs behind a recliner chair, stained bathroom walls, black substances on the tile and floor, missing grout, and heavily soiled floor corners in the resident's room. A similar lack of cleanliness was observed in another resident's bathroom, with stains, missing grout, and black substances present. Interviews with the Housekeeping Manager revealed that these issues had not been reported through the facility's maintenance log, and the concerns behind the toilets had not been addressed. The Corporate Nurse confirmed that staff were expected to report such concerns to the appropriate department head. The facility's assessment indicated that department managers were responsible for maintaining inventory and ensuring preventive maintenance and cleaning schedules were in place, but these procedures were not followed in this instance.
Failure to Notify Family of New Antiviral Medication and Suspected Shingles
Penalty
Summary
The facility failed to notify the family of a resident with severe cognitive impairment, Down syndrome, and intellectual disabilities when a new antiviral medication was started for a possible shingles infection. Clinical documentation showed that the resident developed 12 intact blisters on the left side, prompting the nurse to suspect shingles and contact the physician, who then ordered Valcyclovir. However, there was no documentation that the resident's family was informed about the new medication order or the presence of blisters related to the suspected infection. Staff interviews confirmed that family notification did not occur and that such notifications are expected to be documented, but the facility lacked a specific policy on family notifications.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) Assessment within the required federal guidelines for one resident. Clinical record review showed that the resident was discharged from the facility on 11/8/24, as documented in both the Census Line and Discharge Summary Note of the Electronic Health Record (EHR). However, upon review of the MDS Section of the EHR on 3/11/25, there was no evidence that a discharge MDS had been set up or completed for this resident. The MDS Coordinator stated that discharge MDS Assessments are typically set up on the day of discharge and are double-checked by the social worker, but she was unsure how this assessment was missed. The Nurse Consultant confirmed that the facility does not have a specific policy for MDS completion and follows the Resident Assessment Instrument (RAI) guidelines, which require a discharge assessment to be completed no later than 14 days after discharge.
Failure to Complete and Document Wound Care and Assessments
Penalty
Summary
The facility failed to complete and document appropriate assessments and interventions for a resident with multiple skin impairments, including a stage three pressure ulcer and bullous pemphigoid. The resident required substantial to maximal assistance with mobility and had diagnoses including hypertension, diabetes, septicemia, and cerebral infarction. The care plan and physician orders directed specific wound care treatments, weekly skin assessments, and dietary interventions, including the use of Juven for wound healing. However, there was a lack of follow-up and clarification regarding the dietary recommendation for Juven, and it was not initiated as recommended by the registered dietician. Observations and record reviews revealed that wound care was not consistently provided or documented according to orders. Staff applied treatments to areas not specified in the physician orders, such as the left buttocks and posterior left thigh, and used foam dressings not included in the treatment orders. Weekly skin assessments and measurements for all affected areas were not completed or documented, and there was no clear record of the progress or status of the wounds, including whether they were improving or deteriorating. Additionally, the clinical record did not reflect that all open areas, such as the left hip, were being treated per the hospital wound clinic's recommendations. Interviews with facility staff confirmed gaps in communication and documentation. The ADON acknowledged that weekly skin assessments were not performed on all areas and that there was no follow-up with the physician regarding the dietary supplement recommendation. The facility's own policy required weekly updates and physician notification for new or worsening wounds, but these procedures were not followed, resulting in incomplete care and documentation for the resident's skin conditions.
Failure to Complete Fall Assessment and Interventions After Resident Fall
Penalty
Summary
The facility failed to provide adequate nursing supervision and follow established protocols to prevent accidents and injuries for a resident identified as being at risk for falls. The resident, who had intact cognition but required substantial to maximal assistance with bed mobility and transfers, experienced a fall while being assisted from a commode to a recliner. The care plan indicated the resident was at risk for falls and included interventions such as the use of a call light for assistance, appropriate footwear, and nonskid strips for safety. Despite these interventions, the resident became weak during a transfer, was lowered to the floor by a CNA, and sustained an abrasion from the nonskid strips. Following the incident, there was a lack of documentation regarding a new fall intervention, root cause analysis (RCA), and follow-up fall assessments, including vital signs. The incident report did not include a new intervention or RCA, and the care plan was not updated to reflect any changes after the fall. Staff interviews revealed uncertainty about whether a gait belt was used during the transfer, and it was noted that some staff used gait belts inconsistently. The CNA involved could not recall if a gait belt was used, and the resident reported that staff varied in their use of this safety device. Further interviews with nursing staff and administration confirmed that the required risk management and RCA processes were not completed due to incorrect coding of the incident report. The facility's policy required all accidents and incidents to be reported, investigated, and reviewed, with immediate actions and interventions documented. However, these procedures were not followed after the resident's fall, resulting in a failure to implement additional safety measures or conduct a thorough investigation as required by facility policy.
Failure to Provide Physician-Ordered Respiratory Care
Penalty
Summary
The facility failed to provide physician-ordered respiratory care for three residents with significant cardiac and respiratory diagnoses. For one resident with atrial fibrillation, heart failure, and respiratory failure, observations showed her oxygen cannula was not connected to the concentrator, leaving her without prescribed oxygen. Family members reported repeated incidents where the resident's oxygen supply was disconnected or depleted, including during out-of-facility appointments and while in the dining room, with staff unaware of the issue. Care conference notes documented ongoing family concerns about the resident not receiving oxygen as ordered. Another resident with atrial fibrillation and pneumonia was observed receiving oxygen at a higher flow rate than ordered, with staff unaware of the correct physician order, which had not been processed after hospital discharge. A third resident with coronary artery disease and respiratory failure was seen short of breath and flushed while using a portable oxygen tank that was empty, with staff failing to monitor and replace the tank as needed. The facility lacked a policy for following or documenting physician orders, and staff interviews confirmed gaps in communication and adherence to prescribed respiratory care.
Failure to Use Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) during care for a resident who had recently returned from the hospital with a feeding tube due to aspiration pneumonia. Nursing notes indicated that the resident was totally dependent on staff for transfers, toileting, and meals, and tube feedings were initiated upon return to the facility. During an observation, a registered nurse donned disposable gloves but did not wear a gown while administering tube feedings and water flushes through a syringe. Facility policy required staff to use EBP, including gowns, for residents with indwelling medical devices such as feeding tubes, and staff were expected to be competent in these precautions.
Pest Control Deficiency Leads to Bed Bug Infestation
Penalty
Summary
The facility failed to establish and implement an effective pest control program, leading to an infestation of bed bugs in the rooms of two residents. On December 8, 2024, staff reported the presence of bugs in the room shared by two residents. Despite the initial sighting, staff were uncertain about the steps to take to mitigate the spread of the pests, which were later confirmed to be bed bugs. The facility lacked a specific policy or procedure for dealing with such infestations, resulting in confusion and delayed action. Resident #1, who had a moderate cognitive deficit and required substantial assistance with daily activities, was moved to a different room after bugs were found. However, the resident expressed uncertainty about the situation and desired to return to his original room. Resident #2, who had intact cognitive ability and was independent in most activities, passed away shortly after the incident. The housekeeping staff removed a recliner from the room, but other items were left, and the residents were not immediately relocated or showered. Interviews with staff revealed a lack of training and awareness regarding pest control procedures. The Housekeeping Supervisor and other staff members were unsure of the appropriate actions to take, and there was no documentation of skin assessments for the residents. The pest control company confirmed the presence of bed bugs on December 10, 2024, but the facility's response was inadequate due to the absence of a detailed policy and staff education on handling such situations.
Failure to Adhere to Food Safety and Infection Control Standards
Penalty
Summary
The facility failed to store, prepare, serve, and distribute food in accordance with professional standards. Observations revealed that staff members, including the Cook/Dietary and Dietary Manager, inconsistently practiced hand hygiene while donning and doffing gloves during meal preparation and service. Staff A was observed touching various surfaces and food items without changing gloves or washing hands properly. Similarly, the Dietary Manager and Staff B also failed to perform hand hygiene between glove changes and upon entering the kitchen, which is against the facility's infection control policies. Additionally, the resident unit refrigerator was found to be improperly maintained. The refrigerator, located in the staff break room, lacked a temperature log and contained multiple items without names or opened dates. Some items were significantly past their best-by dates, and the freezer was dirty and disorganized. The Administrator acknowledged that there was no designated person responsible for monitoring the refrigerator, despite the facility's policies requiring regular checks and proper labeling of food items. These deficiencies indicate a failure to adhere to infection control and food safety standards as outlined in the facility's policies.
Failure to Complete PASRR Evaluation for Resident with New Diagnoses
Penalty
Summary
The facility failed to refer a resident with an initial negative Level I result for the Pre-Admission Screening and Resident Review (PASRR) to the appropriate state-designated authority for a Level II PASRR evaluation and determination. This deficiency was identified for one of four residents reviewed. Specifically, Resident #14 had a Minimum Data Set (MDS) indicating severe cognitive impairment and diagnoses of non-Alzheimer's dementia, depression, and bipolar disorder. Despite these new diagnoses, the facility did not complete a new PASRR evaluation as required by regulations. During interviews, staff acknowledged that a new PASRR should have been completed following the new diagnoses. The Social Services staff and the Director of Nursing (DON) both stated that their expectation was for a new PASRR evaluation to be conducted after any new diagnosis that could potentially change the PASRR status. However, the facility did not have a specific policy for PASRR and claimed to follow the regulations, which led to the oversight in Resident #14's case.
Failure to Review PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that as-needed (PRN) orders for psychotropic medications did not exceed 14 days without physician review for one resident. Resident #52, who had severe cognitive impairment with diagnoses of Alzheimer's disease, anxiety, and depression, had a PRN order for lorazepam intensol oral concentrate without a specified stop date. The medication was administered 15 times in March, 31 times in April, and 4 times in May. The Director of Nursing (DON) acknowledged that the PRN psychotropic medication had not been reviewed with the physician and stated that the facility did not have a policy for reviewing PRN psychotropic medications, although they followed regulations.
Failure to Obtain Bed Hold Notifications
Penalty
Summary
The facility failed to obtain bed hold notifications for four residents who were transferred to the hospital or on therapeutic leave. Specifically, Resident #11 had an unpaid hospital leave from 11/14/23 through 11/17/23, Resident #45 had a discharged hospital stay from 4/26/24 through 5/1/24, Resident #15 had an unpaid hospital leave from 4/1/24 to 4/5/24, and Resident #43 had an unpaid hospital leave from 2/2/24 to 3/5/24. In all these cases, the facility did not provide the required bed hold notifications as mandated by federal regulations. During an interview, the Director of Nursing (DON) acknowledged that the facility did not have the bed hold notifications for the mentioned residents and believed that social services were responsible for completing them. The facility's policy, dated 5/15/23, requires providing written notice regarding transfer to the hospital and appeal rights, but this was not adhered to in these instances. The facility reported a census of 50 residents at the time of the survey.
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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