Accura Healthcare Of Cresco
Inspection history, citations, penalties and survey trends for this long-term care facility in Cresco, Iowa.
- Location
- 701 Vernon Road Sw, Cresco, Iowa 52136
- CMS Provider Number
- 165490
- Inspections on file
- 25
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Accura Healthcare Of Cresco during CMS and state inspections, most recent first.
The facility did not ensure that an RN was on duty for at least eight consecutive hours on multiple days over a multi‑month period, despite having a census of 26 residents. Review of nursing schedules and staff interviews confirmed repeated dates with no RN coverage, and the Administrator acknowledged that RN staffing was an ongoing problem. The facility assessment noted that the facility was working toward meeting minimum staffing requirements.
A resident with paraplegia and a stage 4 sacral pressure ulcer had specific wound clinic orders for acetic acid application, Calmoseptine to the buttock wound, Melgisorb Ag to the wound base, air time, and then ABD dressing with tape. An RN did not leave the acetic acid–soaked gauze in place for the ordered duration, did not provide ordered air time, placed the resident on the bed without a barrier and with the wound uncovered, and repeatedly touched the computer and wound care supplies without performing hand hygiene. The RN also used the same gloved hand to apply Calmoseptine to multiple wounds and then handle and cut Melgisorb Ag before dressing the wound and documenting the treatment as completed per orders.
Two residents were transferred to other facilities without completed discharge summaries or necessary documentation. Both residents arrived at their new locations without paperwork, causing delays in obtaining admission orders and necessary treatments. Receiving providers had to contact the original facility multiple times to obtain essential information for ongoing care.
Two residents with PICC lines did not have care plans that documented the presence of the device, associated risk factors, or required monitoring, despite receiving IV medications and having relevant medical conditions. This was confirmed through record review, staff interview, and policy review.
The facility did not follow professional standards for assessing and documenting the status of PICC lines for two residents receiving IV medications. For both residents, there was no documentation of PICC site, location, or length assessments in the medical record, and required monitoring per facility policy was not performed or recorded.
A resident's trust account was not closed within the required timeframe after discharge, and the facility continued to deposit and withdraw funds from the account without the resident's knowledge or authorization. The resident was cognitively intact and managed his own finances, yet the facility failed to follow policy and regulatory requirements for account closure and proper authorization of transactions.
After the departure of the Restorative Aide, the facility discontinued all restorative programs for several residents with no documentation or rationale, and failed to conduct required monthly reviews. Staff interviews revealed a lack of training and oversight, with the DON confirming that programs were ended for staff convenience rather than resident need.
A resident with multiple chronic conditions and at risk for pressure ulcers was found by a CNA to have an open, red, and bleeding scrotum during a shower. The issue was documented on a skin monitoring form, but there was no evidence that a nurse assessed the area or that a physician was notified as required by facility policy. The DON was not informed at the time, and the area was not properly tracked or monitored.
A resident with cognitive impairment and multiple diagnoses did not receive prescribed artificial tears for 14 days due to supply issues, with no documentation of physician notification or timely pharmacy ordering. Staff interviews confirmed awareness of the shortage, and facility policy lacked clear instructions for handling unavailable medications.
A resident with severe cognitive impairment and a history of wandering accessed a key code locked basement door, fell down the stairs, and sustained injuries including a hematoma and abrasions. The care plan identified elopement and fall risks, but the resident was able to bypass the locked door, and staff were unaware of the door's vulnerability. The incident revealed a failure to ensure a hazard-free environment and adequate supervision.
A Dietary Manager's personnel file lacked documentation of required dependent adult abuse training within the mandated timeframe. Facility policy requires this training for all employees, but the employee could not provide proof of completion, and the Administrator confirmed the absence of documentation.
A resident with severe cognitive impairment and behavioral issues kicked another resident, who also had severe cognitive impairment and was on hospice care. Despite facility policy requiring notification, neither the family nor the physician of either resident was informed of the incident, and this was confirmed by staff interviews and clinical record review.
A resident with severe cognitive impairment and a history of aggressive behaviors repeatedly physically and verbally targeted another resident with significant cognitive and physical disabilities. Despite multiple documented incidents and staff awareness of the ongoing abuse, the care plan lacked interventions to address or prevent these behaviors until after a major incident occurred. Staff interviews confirmed the pattern of aggression and the absence of timely reporting or protective measures.
A resident was kicked in the face by another resident in the dining room, an incident witnessed by dietary staff. The facility did not report this abuse allegation to the Iowa Department of Inspections, Appeals, and Licensing as required by policy, and there was no documentation of the event being reported.
A resident with severe cognitive impairment and a documented history of physical and verbal aggression repeatedly exhibited abusive behaviors toward another resident and staff, including kicking and hitting, over an extended period. Despite these incidents being recorded in progress notes, no care plan interventions or investigations were initiated until much later, contrary to facility policy requiring prompt investigation of abuse.
A facility failed to complete a background check for a CNA before employment, violating its abuse prevention policy. The CNA worked several shifts over months without the required checks, despite the facility's policy mandating screening for abuse history prior to hiring. The Business Office Manager could not locate the background check and was unsure why it was not completed.
The facility was found deficient in maintaining cleanliness and proper maintenance in its kitchen and dining areas. Observations revealed multiple stains on the dining room carpet and a large black discoloration on the kitchen stove cooktop. Additionally, the kitchen floor had missing tile sections with black discoloration. The DON confirmed that the carpet's condition had been discussed in QA meetings due to infection control concerns, but no plan was in place to address it.
A facility failed to implement comprehensive care plans for two residents. One resident with a Stage 4 pressure ulcer lacked specific interventions in her care plan. Another resident on psychotropic medications and with HSV did not have documented adverse reaction monitoring or interventions in her care plan. The DON acknowledged these deficiencies.
A facility failed to conduct daily nursing assessments for a resident who tested positive for SARS-CoV-2. The resident, who was very weak and required assistance with all cares, did not have any documented assessments or vital signs on a specific day, indicating a lapse in care. The DON expected routine assessments every 12 hours, but this was not adhered to, leading to a deficiency in the care provided.
A facility failed to complete required pre and post-dialysis assessments for a resident with renal insufficiency, as documented in their care plan. The resident, who is cognitively intact, receives dialysis three times a week. A review of the EHR showed missing assessments over a 90-day period. Staff interviews confirmed the assessments were not completed, and the facility lacked a dialysis policy.
A facility failed to ensure proper monitoring and documentation for a resident on anti-viral medication. The resident's EHR lacked the HSV diagnosis, and the valacyclovir prescription did not specify a diagnosis. The care plan did not document the HSV diagnosis or necessary interventions, and the pharmacy did not review the medication usage. The DON expected pharmacy oversight, as outlined in the Medical Director's responsibilities.
The facility failed to notify residents or their representatives of the bed-hold policy during hospital transfers. Record reviews showed that two residents were hospitalized without documentation of notification. The DON confirmed the absence of such documentation, despite the facility's policy requiring nurses to complete a packet including the bed-hold notice during transfers.
The facility did not have a Registered Nurse (RN) on duty for eight consecutive hours on several days, as required by federal regulations. A review of RN timesheets showed the absence of an RN on specific dates, which was confirmed by the Administrator. The facility had 27 residents at the time.
A resident with cognitive impairment repeatedly eloped from a facility due to unsecured doors and inadequate lighting. The resident accessed an unlocked medication cart, taking cigarettes and going outside unsupervised. Staff interviews and observations confirmed that medication carts were often left unattended, and the facility failed to address maintenance issues, contributing to the resident's elopement.
A resident reported waiting 45 minutes for assistance, highlighting the facility's failure to answer call lights within the professional standard of 15 minutes due to staffing issues. Additionally, the facility did not provide restorative exercises as per the resident's care plan, as confirmed by staff interviews. The lack of an active restorative program was attributed to low staffing levels, with a restorative aide often reassigned to other duties.
The facility failed to properly manage and secure narcotic medications, with issues in documentation and accountability. A resident received Baclofen without a nurse's signature, and staff often failed to sign Controlled Drug Count Records. Interviews revealed that the ADON accessed medication carts and administered drugs without proper documentation. The facility's policy for handling narcotics was not consistently followed, leading to significant deficiencies in medication management.
The facility failed to provide necessary treatment supplies for two residents, resulting in incomplete wound care due to the unavailability of Silversorb gel and other items. Additionally, staff lacked access to a policy and procedure book, as the Administrator provided an employee handbook instead. The Administrator acknowledged the issue of restricted access to the P drive where policies were stored, and efforts were underway to organize a policy book.
A resident with cognitive impairments and a history of elopement was able to leave a secure courtyard area due to a malfunctioning garage door latch and nonfunctional floodlights. The facility allowed residents to enter the courtyard unattended, contributing to the incident. The administrator failed to report these issues to the corporate office, and the maintenance director only temporarily secured the door, leading to multiple elopement incidents.
A facility failed to report alleged financial exploitation and drug diversion to management and state authorities. Staff reported missing narcotics and muscle relaxers, but the Administrator allegedly ignored these reports. Staff feared retaliation for contacting corporate. The Administrator received a report of drug diversion late, and the Regional Clinical Quality Specialist was only informed of Flexeril discrepancies. The facility's policy required immediate reporting of such issues.
A facility failed to maintain an accurate care plan for a resident with COPD and incontinence. The resident's care plan, requiring assistance with a walker and gait belt, was not updated to reflect a change in mobility status to modified independence with a front-wheeled walker indoors. This discrepancy was confirmed by a CNA, highlighting a failure to adhere to the facility's policy for timely care plan updates.
The facility failed to assess pressure areas for two residents and did not follow medication orders for a resident, leading to delayed treatment and dissatisfaction. A resident's pressure area was not assessed for several days, and another resident's medications were administered late, contrary to the facility's policy.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to provide required Registered Nurse (RN) coverage for eight consecutive hours per day on 26 days between November 1, 2025, and January 25, 2026, while reporting a census of 26 residents. Review of nursing schedules showed that in November 2025 there was no RN coverage on the 8th, 9th, 15th, 16th, 22nd, 23rd, 27th, 29th, and 30th; in December 2025 there was no RN coverage on the 6th, 7th, 13th, 14th, 20th, 21st, 25th, 27th, and 28th; and in January 2026 there was no RN coverage on the 1st, 3rd, 4th, 11th, 17th, 18th, 24th, and 25th. Staff interviews and schedule review confirmed that the facility did not have an RN in the building for the required eight hours on these dates. The Administrator acknowledged that RN coverage was an ongoing issue and verified the lack of RN coverage on the identified dates. The facility assessment documented that the facility would continue working toward a staffing level that meets the minimum staffing final rule. No specific resident medical histories or conditions at the time of the deficiency were described in the report.
Failure to Follow Ordered Pressure Ulcer Treatment and Aseptic Technique
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer treatment as ordered for a resident with a stage 4 sacral pressure ulcer and paraplegia. The resident’s MDS showed intact cognition with a BIMS score of 15 and documented diagnoses including paraplegia and a stage 4 sacral pressure ulcer. Wound clinic orders dated 12/18/25 directed staff to apply acetic acid–dampened gauze to the wound base and surrounding skin and leave it in place for 10–15 minutes, then remove it, apply Calmoseptine around the left buttock wound, apply Melgisorb Ag (calcium alginate) to the wound base, pat dry, allow 30 minutes of air time, and then return to place an ABD pad secured with Medipore tape. During an observed wound treatment, the RN reviewed the order on the computer, performed hand hygiene, donned gloves, and opened gauze, placing half of it on supplies without a barrier. The RN touched the computer with gloved hands, dampened gauze with acetic acid, and cleansed the wound but did not leave the acetic acid–dampened gauze in place for the ordered 10–15 minutes. The resident was rolled onto her back without a barrier and the area was left uncovered while the RN applied pain cream to the resident’s shoulder. Later, the RN again touched the computer and then donned gloves without hand hygiene, used a gloved finger to obtain and apply Calmoseptine to two sacral wounds, and with the same gloved hand handled and cut Melgisorb Ag and placed it on the wound base. The RN then changed gloves without performing hand hygiene, applied an ABD pad, secured it with tape, and documented completion of the treatment. The DON acknowledged that the treatment was not completed per the physician’s orders.
Failure to Provide Discharge Summaries and Documentation During Resident Transfers
Penalty
Summary
The facility failed to complete and provide discharge summaries and necessary documentation to the receiving facilities for two residents who were transferred. For one resident with intact cognition and diagnoses including cellulitis, lymphedema, and hypertension, the electronic health record did not contain a completed discharge summary or evidence of communication with the receiving provider. The receiving facility reported delays in obtaining admission orders, which resulted in delayed medication and treatments, as the resident arrived without any paperwork or discharge summary. The facility's own discharge planning policy requires all relevant information to be provided in a discharge summary to facilitate a smooth transition and avoid unnecessary delays. Another resident, also with intact cognition and diagnoses of depression, anemia, and hypertension, was discharged to another facility without a completed discharge summary or documented communication with the receiving provider. The resident reported that the discharge process was rushed, and no discharge paperwork or orders were sent with her. The receiving facility confirmed that no discharge records accompanied the resident and that they had to repeatedly contact the prior facility to obtain the necessary information for care.
Failure to Address PICC Line Care in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement care plans that addressed the presence of Peripherally Inserted Central Catheters (PICC) and associated risk factors for two residents. For one resident with severely impaired cognition and diagnoses including heart failure, anemia, and hypertension, the care plan did not document the existence of a PICC line or include interventions and monitoring related to the device, despite the resident receiving IV medications through the PICC. The Director of Nursing acknowledged that the care plan lacked this essential information. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension was discharged from the hospital with a PICC line and received IV medications in the facility. However, the care plan for this resident also failed to document the presence of the PICC line, associated risk factors, or necessary monitoring. These omissions were identified through clinical record review, staff interview, and policy review, and were inconsistent with the facility's policy requiring comprehensive, person-centered care plans that address all identified needs and services.
Failure to Assess and Document PICC Line Status for Residents Receiving IV Therapy
Penalty
Summary
The facility failed to follow professional standards for the assessment and documentation of Peripherally Inserted Central Catheter (PICC) lines for two residents who required IV medications. For one resident with severe cognitive impairment and diagnoses including heart failure, anemia, and hypertension, there was no documentation in the electronic health record of any assessment of the PICC site, its location, or length during the resident's stay. The admission assessment also did not note the presence of a PICC line, and the discharge summary indicated the central line was removed due to occlusion. The Director of Nursing confirmed that nurses were expected to assess the site when administering medication but acknowledged that there was no documentation to support that these assessments occurred, nor were measurements of the catheter performed to ensure it had not moved out of place. Similarly, another resident with intact cognition and diagnoses of osteomyelitis, pneumonia, and hypertension had a PICC line on admission, but the electronic health record lacked documentation of any assessment of the PICC site, location, or length. The admission assessment also failed to document the presence of a PICC line. Facility policy required nurses to monitor the dressing, line, and resident every shift for signs of infection, malposition, or occlusion, and to document these assessments, but this was not done for either resident.
Failure to Timely Close Resident Trust Account and Unauthorized Transactions Post-Discharge
Penalty
Summary
The facility failed to close a resident's trust account within 30 days of discharge, as required by both facility policy and federal regulations. After discharge, the resident, who was cognitively intact and managed his own financial affairs, continued to have income deposited into and funds withdrawn from his trust account by the facility without his knowledge or authorization. The facility was not the representative payee for the resident, and there was no documentation authorizing these post-discharge transactions. Bank statements and trust transaction histories confirmed that deposits and withdrawals occurred for several months after the resident's discharge. Additionally, the facility did not provide documentation that the trust account had been closed or that a refund of the remaining balance had been processed in a timely manner. The administrator acknowledged the ongoing balance in the account and the lack of proper authorization for the transactions. Facility policy required that trust accounts be closed within 24 hours of discharge and refunded within 30 days, with all disbursements properly authorized, but these procedures were not followed in this case.
Failure to Document and Maintain Restorative Programs After Staff Departure
Penalty
Summary
The facility failed to provide documentation and rationale for discontinuing restorative programs for three residents after the designated Restorative Aide left the restorative nursing department. Record reviews showed that for each resident, restorative programs such as active range of motion exercises and other therapeutic activities were discontinued on the same date, with no evidence of monthly restorative program reviews or documented reasons for stopping the interventions. The residents involved had varying degrees of cognitive impairment and physical limitations, including needs for assistance with ambulation, dressing, and other activities of daily living, as well as diagnoses such as diabetes, obesity, muscle weakness, heart failure, anxiety, and depression. Interviews with facility staff revealed that the MDS Coordinator, who was responsible for overseeing the Restorative Program, had minimal training and had not completed any charting or reviews of restorative plans since assuming the role. The discontinuation of all restorative programs was attributed to the absence of a trained Restorative Aide, and no alternative arrangements or documentation were made to continue or review the programs. The Director of Nursing confirmed that all restorative programs were resolved or discontinued for staff convenience, and there had been no RN monthly restorative reviews for any residents in the past six months.
Failure to Document Nursing Assessment After Skin Issue Identified
Penalty
Summary
A deficiency occurred when the facility failed to document a nursing assessment after a bath aide identified an open, red, and bleeding scrotum on a resident. The resident, who had diagnoses including diabetes, heart failure, and chronic obstructive pulmonary disease, was dependent on staff for toileting hygiene and required substantial assistance with transfers. The resident was also at risk for pressure ulcers. The Certified Nursing Assistant (CNA) documented the skin issue on a shower review form, but there was no evidence in the progress notes from the date of discovery through several days later that a nurse assessed the area or that a physician was notified. Interviews revealed that the CNA reported new skin issues using a designated form, which was then placed in the MDS Coordinator's mailbox. The MDS Coordinator charted a note several days after the initial finding but did not verify that the area was tracked or monitored. The Director of Nursing (DON) was not made aware of the issue at the time and did not assess the area until days later, by which time only chronic redness was observed. Facility policy required notification of the DON and wound nurse for new skin alterations, completion of incident reports, and physician notification if deterioration or infection was observed, but these steps were not documented as completed in this case.
Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, diabetes, dementia, and hemiplegia did not receive their ordered artificial tears for 14 days, missing 55 doses. The September Medication Administration Record showed the medication was not administered from 9/10/25 through 9/24/25. There was no documentation in the resident's progress notes indicating that the physician was notified about the unavailability of the artificial tears or that the resident was not receiving the medication as ordered. Staff interviews revealed that the facility was aware the artificial tears were on back order with the stock supply distributor, but the medication was not ordered through the pharmacy until 9/24/25, when a nurse called the pharmacy and the medication was delivered later that day. The facility's policy instructed nurses to report supply deficiencies to the DON but did not provide guidance on notifying the prescriber or pharmacist when medications were unavailable. The DON confirmed that the physician should have been notified when medications were not received.
Resident with Cognitive Impairment Accesses Locked Door, Falls Down Stairs
Penalty
Summary
A resident with severe cognitive impairment, dementia, and a history of wandering and elopement risk was not adequately protected from accident hazards within the facility. The resident's care plan identified risks for elopement and falls, directing staff to provide supervision, diversions, and structured activities to prevent wandering. Despite these interventions, the resident was last seen in the dining room with staff before going missing. Staff initiated a search, including looking outside, and eventually found the resident at the bottom of a basement staircase, having accessed a key code locked door with his wheelchair and fallen down the stairs. The incident report documented that the resident sustained a hematoma to the face and right forearm, as well as an abrasion and bruise to the left hand, requiring evaluation at the emergency room. Staff interviews revealed that the resident may have figured out the code to the basement door, which was supposed to be locked. Observations showed that the door had a key code lock with a deadbolt latch that, if turned, would allow the door to open without entering the code, although the keys would still light up as if the code was being entered. Staff were generally unaware that the door could be accessed in this manner, and some were not even aware of the basement's existence. The maintenance staff confirmed that the door and lock were functioning as intended upon inspection, and that the door was supposed to lock automatically. However, the incident demonstrated that the resident was able to access the basement, leading to a fall and injury. The facility census at the time was 29 residents, and the event highlighted a failure to ensure the environment was free from accident hazards and that adequate supervision was provided to prevent accidents for this resident.
Lack of Documentation for Dependent Adult Abuse Training
Penalty
Summary
The facility failed to provide required dependent adult abuse training within six months of hire for one of five employees reviewed. Personnel file review for the Dietary Manager showed a hire date of 1/20/23, but there was no documentation of the mandatory Dependent Adult Abuse training in the employee's file. Facility policy requires each employee to complete a two-hour initial training, followed by a one-hour recertification every three years. During an interview, the Administrator confirmed that the training documentation was missing from the employee's file, and the employee was unable to provide proof of completion, despite claiming to have taken the training in 2023.
Failure to Notify Family and Physician of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to notify both the family and physician of an incident involving resident-to-resident abuse. Specifically, a resident with severe cognitive impairment and a history of physical and verbal behaviors was documented as having kicked another resident in the face. Progress notes indicated that the nurse observed the incident and addressed the behavior with the resident, but there was no documentation that the physician or the family of either resident involved were informed of the event. The facility's risk management policy requires that such incidents be reported to the appropriate parties, including the physician and family, and that a progress note be entered in the resident's chart. Both residents involved had severe cognitive impairment, with one resident also diagnosed with Alzheimer's disease, Down Syndrome, and moderate intellectual disabilities, and was on hospice care. Despite these vulnerabilities, the clinical records for both residents lacked evidence that their families or physicians were notified about the incident. Staff interviews confirmed that the family should have been informed, but this did not occur, constituting a failure to follow facility policy and ensure appropriate communication after a significant event.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from repeated physical abuse by another resident, despite multiple documented incidents of aggressive behavior. One resident with severe cognitive impairment and a history of both physical and verbal aggression, including wandering, was involved in several altercations targeting another resident. These incidents included attempts to kick, ramming with a wheelchair, verbal insults, and physical attacks such as kicking in the face and legs. Staff progress notes documented a pattern of escalating behaviors over several months, with specific references to the aggressor seeking out and targeting the same resident multiple times. Despite these ongoing incidents, the resident's care plan did not include interventions to address or prevent abusive behaviors toward others until after a significant incident occurred. Staff interviews confirmed awareness of the aggressor's pattern of seeking out and attempting to harm the other resident, yet no specific measures were implemented to prevent further abuse prior to the addition of interventions on the care plan. The facility's own abuse prevention policy defines resident-to-resident physical contact resulting in harm, pain, or mental anguish as abuse, and presumes such outcomes in residents with cognitive or physical impairments, even if no immediate injury is observed. The resident who was targeted had severe cognitive impairment, Alzheimer's disease, Down Syndrome, moderate intellectual disabilities, and was on hospice care. There were no behaviors noted for this resident during the assessment period. Staff and administrative interviews revealed a lack of timely reporting and investigation of the incidents, as well as a failure to notify family and the physician. The deficiency centers on the facility's inaction in updating the care plan and implementing protective interventions despite clear evidence of ongoing abuse.
Failure to Report Resident-to-Resident Abuse to Authorities
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) as required by policy. Specifically, a resident was kicked in the face by another resident in the dining room, an event witnessed by dietary staff. Review of facility records showed no documentation that this incident was reported to DIAL. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be reported to the appropriate authorities within specified timeframes, but this protocol was not followed in this case. The administrator confirmed during an interview that such incidents should be reported to DIAL, yet the required reporting did not occur.
Failure to Investigate and Intervene in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and implement interventions in response to multiple incidents of resident-to-resident abuse involving a resident with severe cognitive impairment and a history of physical and verbal aggression. Clinical record review showed that this resident exhibited repeated aggressive behaviors, including kicking, hitting, and verbal abuse directed at another resident and staff over several months. Despite documentation of these behaviors in progress notes, there were no care plan interventions addressing the resident's abusive behaviors toward others until a focused area and interventions were added months after the initial incidents. Interviews with facility leadership confirmed that no actions were taken to address or investigate the incidents prior to the addition of care plan interventions. The administrator stated that she would have investigated the abuse if she had been made aware of it, and the DON acknowledged that staff did not report the incidents as required. Facility policy directs that any observed or suspected abuse should be investigated by management, but this protocol was not followed in these cases.
Failure to Complete Background Check for CNA
Penalty
Summary
The facility failed to complete a background check for one of its current employees, a Certified Nurse Aide (CNA) referred to as Staff B, prior to employment. This deficiency was identified during a review of records, staff interviews, and policy review. The facility's policy mandates that all potential employees be screened for a history of abuse, neglect, exploitation, misappropriation of property, or mistreatment of residents before hiring. However, the background check for Staff B was only completed on January 8, 2025, despite her having worked several hours at the facility since August 2024. During an interview, the Business Office Manager was unable to locate the background check for Staff B when requested. She stated that she typically runs a background check before hiring an employee and was unsure why it was not completed or if it was misplaced. The facility's policy requires conducting an Iowa criminal record check and dependent adult/child abuse registry check on all prospective employees prior to hire, as per the Iowa Administrative Code. Despite this requirement, Staff B worked multiple shifts over several months without the necessary background check being completed, which is a violation of the facility's abuse prevention policy.
Facility Maintenance and Cleanliness Deficiency
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance in its kitchen and dining areas, as observed during a survey. In the dining room, there were multiple stains on the carpet, with the largest stain measuring approximately 10 feet by 3 feet, located next to lower cabinets in the common areas. In the kitchen, the stove cooktop had a large area of black discoloration on the stainless steel part, and the floor had multiple tiles missing sections with black discoloration between them. The Director of Nursing (DON) acknowledged that the carpet's condition had been discussed in Quality Assurance meetings due to infection control concerns and stains, but no plan was in place to address the issue.
Deficiencies in Care Plan Implementation for Pressure Ulcers and Medication Monitoring
Penalty
Summary
The facility failed to comprehensively assess and implement necessary interventions for pressure ulcers and other medical conditions for two residents. Resident #6, who had a Stage 4 pressure ulcer in the sacral region, did not have specific interventions documented in her care plan to address her condition. This oversight was identified during a record review of her care plan dated 1/7/2024, which lacked resident-specific interventions for her pressure ulcer, despite an After Visit Summary dated 12/5/2024 indicating the severity of her condition. Additionally, Resident #24, who was on multiple psychotropic medications, did not have a care plan that documented adverse reactions to monitor for or interventions and goals related to her medication use. Furthermore, her care plan lacked documentation of her diagnosis of Herpes Simplex Virus (HSV) and the necessary interventions and monitoring for her condition, despite her admission orders indicating she was on prophylactic Valtrex. The Director of Nursing acknowledged these deficiencies, stating that she would have expected comprehensive care plans for both residents, including interventions for pressure ulcers, psychotropic medication monitoring, and HSV management.
Failure to Conduct Daily Assessments for SARS-CoV-2 Positive Resident
Penalty
Summary
The facility failed to ensure that a resident who tested positive for SARS-CoV-2 received daily nursing assessments as required. The resident, identified as Resident #80, was placed in isolation due to the positive test result. Despite the resident's condition of being very weak and requiring assistance with all cares, the facility did not document any assessments or vital signs for the resident on January 8, 2025. This lack of documentation indicates that no assessments were completed on that day. The Director of Nursing (DON) stated that she would expect a SARS-CoV-2 positive resident to receive routine assessments at least every 12 hours, including a full head-to-toe assessment documented in the resident's Electronic Health Record (EHR). The facility's Agreement for Medical Director Services outlines the responsibilities of the Medical Director, which include the surveillance of the health status of residents and acting as a consultant to the Administrator and/or DON. However, the facility did not adhere to these expectations, resulting in a deficiency in the care provided to Resident #80.
Incomplete Dialysis Assessments for Resident
Penalty
Summary
The facility failed to provide complete dialysis assessments for a resident requiring such services. Resident #16, who is cognitively intact with a BIMS score of 15, has diagnoses including heart failure, hypertension, and renal insufficiency, and receives dialysis three times a week. The care plan for Resident #16 included specific instructions for monitoring vital signs and conducting pre and post-dialysis assessments on dialysis days, as well as monitoring for signs of infection and renal insufficiency. However, a review of Resident #16's Electronic Health Record (EHR) revealed missing pre and post-dialysis assessments on multiple occasions over a 90-day period. Interviews with staff, including a Licensed Practical Nurse and the Director of Nursing, confirmed that these assessments were not completed as required. Additionally, the facility lacked a dialysis policy, which may have contributed to the oversight in completing the necessary assessments.
Failure to Ensure Proper Monitoring and Documentation for Anti-Viral Medication
Penalty
Summary
The facility failed to ensure proper routine monitoring and documentation for a resident receiving anti-viral medication. The resident, who was admitted with a diagnosis of Herpes Simplex Virus (HSV), was prescribed prophylactic valacyclovir. However, the resident's current diagnoses in the Electronic Health Record (EHR) did not include HSV, and the Order Summary Report did not specify the diagnosis for the valacyclovir prescription. Additionally, the resident's progress notes lacked a review by the facility's pharmacist and did not include a request for the rationale behind the valacyclovir usage. Furthermore, the resident's current care plan did not document the HSV diagnosis or the interventions needed for managing the condition. It also failed to mention the anti-viral medication and the potential adverse reactions to monitor. During an interview, the Director of Nursing expressed an expectation for the pharmacy to ensure proper diagnoses are in place for all medications. The facility's agreement with the Medical Director outlined responsibilities for coordinating medical care, including policy development and health status surveillance, but these were not adequately fulfilled in this case.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy to residents or their representatives during hospital transfers, as required. This deficiency was identified through a review of records, staff interviews, and policy documents. Specifically, the records for three hospitalizations involving two residents lacked documentation that the residents or their Power of Attorneys (POAs) were informed of the facility's bed-hold policy. Resident #15 was discharged to the hospital and returned without any record of notification, and Resident #16 experienced two hospitalizations with no documentation of notification. The Director of Nursing confirmed the absence of such documentation and explained that the nurse on duty is responsible for completing a packet that includes the bed-hold notice during acute transfers, which was not done in these cases. The facility's Acute Care Transfer Checklist requires the completion of an emergency notice of transfer/discharge and a notice of bed-hold policy and return, which was not adhered to in these instances.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to comply with federal regulations requiring a Registered Nurse (RN) to be on duty for eight consecutive hours each day. A review of RN timesheets from May 26, 2024, through June 6, 2024, revealed that the facility did not have an RN on duty on May 27, 2024, and from June 4 to June 6, 2024. The facility had a census of 27 residents during this period. The deficiency was confirmed during an interview with the Administrator on June 7, 2024, at 3:15 p.m., who acknowledged the failure to provide the required RN coverage.
Facility Fails to Secure Environment and Medication Carts
Penalty
Summary
The facility failed to maintain a safe and secure environment for a resident with multiple diagnoses, including schizophrenia, bipolar disorder, and moderate cognitive impairment. The resident, who was at high risk for elopement and moderate risk for falls, was found outside the facility on multiple occasions. On one occasion, the resident was found in a garage after leaving the courtyard through an unsecured door. The garage door had been previously reported as faulty, and temporary measures to secure it were inadequate. Additionally, the courtyard was inadequately lit, further compromising safety. Staff interviews revealed that residents were allowed to enter the courtyard unattended, even at night, which contributed to the resident's ability to leave the area unnoticed. The facility's maintenance director confirmed that the floodlight outside the garage was nonfunctional, and the administrator failed to notify the corporate office about the malfunctioning door and lights. This lack of communication and oversight contributed to the resident's repeated elopement incidents. Furthermore, the facility failed to secure medication carts, allowing the resident to access them unsupervised. On one occasion, the resident took cigarettes from an unlocked medication cart and went outside to smoke, later becoming upset when denied another smoke break. Observations confirmed that medication carts were left unlocked and unattended in areas accessible to residents, posing a risk to cognitively impaired individuals.
Staffing Issues Lead to Delayed Call Light Responses and Incomplete Restorative Care
Penalty
Summary
The facility failed to meet the professional standard of answering resident call lights within 15 minutes, as evidenced by interviews with Resident #3 and staff members. Resident #3 reported waiting 45 minutes for assistance, which made her feel neglected. Staff interviews confirmed that call lights were not consistently answered within the required timeframe due to staffing issues. The Resident Council minutes also documented concerns about delayed responses to call lights on multiple occasions. Additionally, the facility did not provide restorative exercises according to the individual plan of care for Resident #3. Interviews with staff, including the Administrator and the Regional Clinical Quality Specialist, revealed that the facility lacked an active restorative program due to low staffing levels. A restorative aide was frequently reassigned to other duties, preventing the implementation of restorative programs. The Director of Rehabilitation Services confirmed that restorative programs were not followed as intended.
Deficiencies in Narcotic Medication Management
Penalty
Summary
The facility failed to properly manage and secure narcotic medications, as evidenced by several deficiencies in the handling and documentation of controlled substances. A review of the Controlled Drug Administration Record for a resident revealed that a Baclofen pill was administered without a nurse's signature to validate who administered the medication. Additionally, there were multiple instances where staff failed to sign the Controlled Drug Count Record forms, indicating that narcotics were not properly counted or accounted for during shift changes. This lack of documentation and accountability was observed on several dates and shifts, leading to discrepancies in the narcotic counts. Interviews with staff members further highlighted issues with the facility's medication management practices. One LPN admitted to not counting narcotics when handing over keys during meal breaks, and it was revealed that the Assistant Director of Nursing (ADON) had access to medication carts and narcotic drawers, administering medications without proper documentation. Staff members reported that the ADON sometimes worked alone and signed off on narcotic sheets without documenting the administration of drugs on the Medication Administration Records (MARS), leading to inaccuracies. The ADON confirmed carrying spare keys to medication carts and narcotic boxes, and the facility's administrator acknowledged that multiple nurses had access to these keys, contributing to medication errors. The facility's Controlled Substances policy outlined procedures for handling, storing, and documenting narcotics, but these were not consistently followed. The policy required a physical inventory of narcotics at each shift change by two nurses, with discrepancies reported immediately to the Director of Nursing. However, the report indicated that these procedures were not adhered to, as evidenced by the lack of proper record-keeping and accountability for controlled drugs. The failure to follow established protocols and secure narcotic medications resulted in a significant deficiency in the facility's medication management practices.
Supply Shortages and Policy Access Issues in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient supplies to meet the treatment needs of two residents. Resident #2 had a treatment order for a stage IV pressure area on the right hip and gluteal region, which required cleansing with wound cleanser, application of Silversorb gel, collagen powder, and an ABD pad daily. However, the facility staff were unable to perform the complete treatment on two occasions due to the unavailability of Silversorb gel. Similarly, Resident #3 had a treatment order for a wound on the right medial third toe, which required cleansing with normal saline and Betadine, but the treatment was not performed on two occasions due to a lack of supplies. Additionally, the facility failed to provide a policy and procedure book readily accessible to staff. Staff members reported that they were unable to access the necessary policies and procedures, as the Administrator directed them to an employee handbook instead. The Administrator acknowledged that the facility staff did not have direct access to the P drive where the policies were stored, and efforts were being made to organize a policy and procedure book. The Regional Clinical Quality Specialist also confirmed the lack of access to the P drive for nurses, and the Director of Nursing had to print and provide copies of the policies for the staff.
Facility Fails to Secure Environment, Leading to Resident Elopement
Penalty
Summary
The facility failed to maintain a safe and secure environment for its residents, as evidenced by multiple incidents involving a resident with a history of schizophrenia, bipolar disorder, and other health issues. This resident, who was at high risk for elopement and moderate risk for falls, was found outside the facility on several occasions. On one occasion, the resident was found in a garage after leaving the courtyard area, which was supposed to be secure. The garage door had been left in disrepair, and the resident was able to access it due to a malfunctioning latch. Staff interviews revealed that residents were allowed to enter the courtyard area unattended, even at night, which contributed to the resident's ability to leave the secure area. The staff's response to the door alarm was delayed, and the resident was unaccounted for several minutes. The facility's maintenance director had been aware of the garage door's disrepair but had only temporarily secured it with a board, which proved insufficient. Additionally, the facility's administrator failed to notify the corporate office about the malfunctioning garage access door and nonfunctional floodlights, which could have prevented the resident's elopement. The facility also identified six other residents who were cognitively impaired and prone to wandering, indicating a broader issue with maintaining a secure environment for vulnerable residents.
Failure to Report Drug Diversion and Financial Exploitation
Penalty
Summary
The facility failed to report alleged violations involving financial exploitation and drug diversion to management and the Iowa Department of Inspections, Appeals, and Licensing as required by policy. This deficiency was identified for one of six residents reviewed. Staff interviews revealed that narcotics and muscle relaxers were reported missing, but the Administrator allegedly ignored these reports. Staff members expressed fear of retaliation if they reported concerns to corporate, as they were instructed not to contact corporate directly. The Administrator admitted that the facility staff did not report the alleged drug diversion directly to her, but rather left a note under her office door, which she did not receive until three days later. The Regional Clinical Quality Specialist was only informed of discrepancies with Flexeril and expected the Administrator to report missing narcotics to the appropriate authorities. The facility's Controlled Substances policy required immediate reporting of discrepancies to the Director of Nursing, who would then initiate an investigation and report missing narcotics to the Clinical Quality Team.
Inaccurate Care Plan for Resident with COPD
Penalty
Summary
The facility failed to maintain a complete and accurate care plan for one of the residents reviewed. The care plan for this resident, who has a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and incontinence, indicated a deficit in activities of daily living (ADLs) due to shortness of breath. The care plan, initiated on August 16, 2022, required the resident to have assistance with a walker and gait belt. However, a Rehab Communication form dated May 28, 2024, indicated a change in the resident's mobility status to modified independence with a front-wheeled walker when indoors, but not outdoors. This change was not reflected in the care plan, as confirmed by a Certified Nursing Assistant during an interview on June 18, 2024. The facility's policy, revised on January 30, 2024, mandates the development and implementation of a comprehensive person-centered care plan for each resident, which should include measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. The policy also requires timely updates to the care plan to ensure that the services provided represent the resident's highest practicable physical, mental, and psychosocial well-being. The failure to update the care plan in accordance with the resident's current needs and the facility's policy led to the identified deficiency.
Failure to Assess Pressure Areas and Follow Medication Orders
Penalty
Summary
The facility failed to provide adequate assessment and intervention for pressure areas in two residents. Resident #2 experienced an increase in drainage from a pressure area on the right hip and buttocks, which was not assessed by the facility on multiple occasions, including 5.21.24, 5.23.24, 5.24.24, 5.26.24, and 5.27.24. Similarly, Resident #3 had a pressure area on the left heel that went unassessed from 4.24.24 to 5.7.24. A corporate representative confirmed the lack of assessment for Resident #3 during an interview. Additionally, the facility failed to follow physician's orders for Resident #3 regarding medication administration. On 6.11.24, medications prescribed to be administered at 7 p.m. were given at 9:43 p.m. The resident expressed dissatisfaction with the delay, as it affected her ability to sleep due to neuropathy. The facility's Medication Administration Policy requires medications to be administered within 60 minutes of the scheduled time, which was not adhered to in this instance. Interviews with staff confirmed the delay and the resident's concerns.
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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