Accura Healthcare Of Creston
Inspection history, citations, penalties and survey trends for this long-term care facility in Creston, Iowa.
- Location
- 1000 East Howard, Creston, Iowa 50801
- CMS Provider Number
- 165275
- Inspections on file
- 20
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Accura Healthcare Of Creston during CMS and state inspections, most recent first.
A resident with significant medical needs, including a feeding tube, did not receive seven scheduled evening medications because a nurse was unable to access the G-tube and did not escalate the issue as expected. The nurse documented the missed doses, and the DON later stated that staff should have sought further assistance. The facility lacked a policy on following physician's orders.
Nursing staff failed to properly administer medications and respond to pain for a resident with a PEG tube. One nurse did not give scheduled medications due to uncertainty about syringe compatibility and did not escalate the issue, while another nurse continued tube feeding despite the resident's complaints of severe pain, later noting abdominal distension. Staff actions did not align with facility policy for feeding tube care and monitoring.
The facility failed to prepare and serve therapeutic meals according to physician orders for three residents with dysphagia, leading to improperly pureed and incorrectly textured diets. A resident with a pureed diet was served food not pureed to the correct consistency, while another resident with a mechanical soft diet was served a regular diet due to a mislabeled tray card. The dietary staff demonstrated inadequate knowledge of proper diet preparation.
The facility failed to maintain proper food temperatures during lunch service, with cold items like creamy cheddar macaroni salad, tomato slices, and deviled eggs exceeding the required 41 degrees Fahrenheit by the end of the meal. Observations showed that cold items were not adequately kept on ice, leading to temperature increases during service.
The facility failed to properly label, date, store, and serve food, with observations of improper glove use and food handling by a cook during lunch service. Despite recent staff education on food safety, these practices were not followed, compromising food safety.
The facility failed to implement proper infection control practices, as staff neglected hand hygiene and equipment sanitation during resident care and medication administration. Observations included improper handling of catheter care, gastric tube site care, and mechanical lift equipment, as well as lapses in hand hygiene during medication administration, including insulin injections and glucometer use.
The facility did not implement required training for five staff members, lacking documentation for completed training in communication, QAPI, compliance and ethics, and behavioral health. Additionally, one staff member did not complete training in resident rights and infection control. The 2024 Mandatory Education calendar required these topics for all staff, but there was no documentation to confirm completion. The DON expected all staff to be current with required training.
The facility did not provide communication training for five staff members hired between March and November 2023, despite it being a required course on the 2024 Mandatory Education calendar. The DON expected all staff to be current with training, but documentation was lacking.
The facility did not provide resident rights training for one staff member, Staff J, who was hired in March 2023. Despite the 2024 mandatory education calendar requiring all staff to complete training on topics including resident rights, there was no documentation showing Staff J's completion of this training. The DON expected all staff to be current with required training, and the facility had a census of 30 residents.
The facility did not provide mandatory QAPI training for five staff members, as required by their education calendar. Despite the Director of Nursing's expectation for all staff to be current with training, there was no documentation confirming completion of QAPI training for these staff members.
The facility did not provide mandatory infection control training for a staff member hired in March 2023. The 2024 education calendar required all staff to complete infection control training, but documentation for this training was missing for one staff member. The DON expected all staff to be current with required training.
The facility did not provide compliance and ethics training for five staff members hired between March and November 2023. Despite being listed as a required course on the 2024 Mandatory Education calendar, there was no documentation of completion for these staff. The DON expected all staff to be current with training, highlighting a lapse in compliance.
The facility did not provide required behavioral health training for five staff members, as revealed by a review of personnel files and the mandatory education calendar. Despite the 2024 education calendar listing behavioral health as a required course, there was no documentation of completion for these staff. The DON expected all staff to be current with training.
The facility failed to notify family and physicians of significant events affecting four residents, including medication errors, a fall, and a change in condition. A resident received incorrect medication dosages without physician notification. Another resident fell, resulting in injuries, but the family was not informed. A third resident experienced delusions after marijuana exposure, but the physician was not updated. These incidents highlight a lack of adherence to notification policies.
The facility failed to update care plans for four residents, leading to deficiencies in care. A resident with swollen legs was on a diuretic, but this was not reflected in their care plan. Another resident, identified as a smoker, lacked smoking safety interventions in their care plan. A third resident's care plan inaccurately described their transfer needs, while a fourth resident's care plan did not include interventions to prevent future falls after an incident.
A resident with severe cognitive impairment experienced a fall while attempting to self-transfer, initially denying pain or injury. The facility's documentation lacked comprehensive post-fall assessments, including vitals and neurological checks. Later, a nurse observed a bruise and the resident complained of leg pain. After transferring to another facility, a fracture was discovered, although no falls occurred there. Hospital records confirmed a right distal femur fracture.
The facility did not document whether a resident wished to appeal the termination of skilled services, as required by policy. The Social Services Manual requires that a Notice of Medicare Non-Coverage (NOMNOC) form be provided to residents two days before service termination, but the facility failed to retain documentation of the resident's decision to appeal. The Social Services Supervisor confirmed that while residents completed the form, the documentation was not kept in the resident's record.
A facility failed to complete a Significant Change MDS within 14 days for a resident admitted to hospice care with cerebral atherosclerosis. The MDS assessment was delayed, contrary to the facility's policy requiring completion within 14 days of a significant change in status. The Regional Director of Nursing indicated that remote MDS Coordinators are responsible for care planning, while on-site staff handle daily updates.
A facility failed to accurately complete the MDS assessment for a resident dependent on HD treatments. Despite the resident's regular HD schedule and documentation in the EHR, the MDS assessment did not reflect these treatments. The interim DON confirmed the omission, which contradicted the facility's RAI/MDS policy.
A facility failed to notify the PASRR program for a resident admitted with mental diagnoses and medications. The resident's PASRR, dated before admission, did not list any mental health conditions or medications, despite the resident having diagnoses of dementia, anxiety, depression, and psychotic disorder, and being on antipsychotic, antianxiety, and antidepressant medications. The social worker confirmed the PASRR was outdated and did not reflect the resident's current medication regimen.
A resident with multiple health conditions did not receive care according to their comprehensive care plan. Staff failed to use a mechanical aid for transfers and did not adhere to the prescribed oxygen settings, leading to deficiencies in care. The resident's oxygen tank was set incorrectly and was empty, and staff transferred the resident manually despite the care plan's directives.
A resident with multiple health conditions was not provided oxygen as per physician orders, receiving 2 LPM instead of the prescribed 3 LPM. Observations showed the oxygen tank was in the refill zone, and staff interviews revealed the facility lacked a policy for following physician's orders.
A facility failed to maintain a medication error rate below 5% during a medication pass. A nurse administered incorrect dosages of Furosemide, Magnesium Oxide, Fiber Lax, and Calcium to two residents, resulting in a 14.8% error rate. The Director of Nursing confirmed that medication orders should be verified against the MAR for accuracy, as outlined in the facility's policy.
A facility failed to maintain a safe environment and proper transfer techniques, as evidenced by an incident where a resident was found with vapes containing nicotine and THC, and another resident was transferred without a gait belt despite being a high fall risk. The facility's policies on smoking and transfer techniques were not followed, leading to these deficiencies.
The facility failed to follow infection prevention standards during incontinence care for two residents. Staff did not change gloves or perform hand hygiene when transitioning from dirty to clean tasks, and the mechanical lift was not disinfected after use. The Director of Nursing confirmed that these actions were against facility policy.
The facility did not review and update its facility-wide assessment annually as required. The last review was documented on 4/26/23, with no updates until 7/10/24. The Regional Director of Clinical Services could not locate the current assessment, and a new one was not completed, despite the facility's policy requiring annual reviews.
The facility did not have a written transfer agreement with a hospital, which is essential for ensuring residents can be transferred for medical care when needed. This was confirmed by the Regional Director of Clinical Services, who noted the absence of both the agreement and a related policy.
A facility failed to update a care plan for a resident with COPD who frequently adjusted her oxygen levels herself. Despite staff and family awareness of this behavior, it was not documented in the care plan, and no specific interventions were implemented to prevent the resident from adjusting her oxygen levels.
Failure to Administer Medications as Ordered Due to Inaccessible G-Tube
Penalty
Summary
A deficiency occurred when staff failed to follow a physician's order for medication administration for a resident with multiple complex medical conditions, including COPD, anxiety, depression, stroke with right-sided hemiplegia, aphasia, and dysphagia. The resident required significant assistance with daily activities and received more than half of their caloric intake via a feeding tube. The physician's order specified that medications could be crushed and administered through the feeding tube every shift. However, on one occasion, the resident did not receive seven scheduled evening medications because the nurse was unable to access the G-tube. The nurse documented the missed medications and stated that he did not believe missing the nighttime medications would be detrimental. The resident later confirmed not receiving the medications. The DON indicated that staff should have contacted the on-call nurse and escalated the issue if necessary. Additionally, the facility administrator acknowledged that there was no policy in place regarding adherence to physician's orders.
Failure to Ensure Competent G-Tube Care and Response to Resident Pain
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in the care of a resident with a PEG feeding tube, resulting in missed medication administration and improper response to pain during tube feeding. The resident, who had moderately impaired cognition and multiple diagnoses including dysphagia, stroke with hemiplegia, and aphasia, was dependent on tube feeding for more than half of his caloric intake. On one occasion, a registered nurse was unable to administer scheduled evening medications because he could not access the resident's new feeding tube, citing the absence of a specific syringe. The nurse did not contact the on-call nurse or escalate the issue, resulting in the resident missing his medications. It was later determined that available piston syringes would have sufficed for medication administration. On a subsequent shift, another nurse continued to administer tube feeding to the same resident despite the resident's complaints of severe pain and visible discomfort. The nurse attributed the resident's reaction to possible hunger or post-surgical tenderness and did not stop the feeding or seek further assessment. The resident's abdomen was later found to be distended and painful upon examination. Facility policy required staff to utilize feeding tubes according to clinical standards and to monitor for complications, but staff failed to follow these protocols, leading to the deficiency.
Improper Preparation of Therapeutic Meals
Penalty
Summary
The facility failed to prepare and serve therapeutic meals in a form designed to safely meet the needs of residents, as per physician orders. This deficiency was identified for three residents who required specific diet textures due to their medical conditions. Resident #9, who had a diagnosis of dysphagia, was supposed to receive a pureed diet with honey-thick liquids. However, during meal preparation, the food was not pureed to the correct consistency, posing a risk of choking or aspiration. Resident #16, also diagnosed with dysphagia, was on a puree diet for pleasure feedings in addition to tube feedings. The resident had a history of coughing during meals and a previous choking incident. Despite these concerns, the food prepared for Resident #16 was not properly pureed, as observed by the State Surveyor. The macaroni salad, intended to be pureed, was not smooth, and the Registered Dietitian later confirmed that it was not appropriately prepared. Resident #25 was ordered a mechanical soft diet but was incorrectly served a regular diet during lunch observation. The tray card for Resident #25 was mislabeled, leading to the resident receiving the wrong diet. The facility's dietary staff, including Staff B, demonstrated a lack of knowledge and adherence to proper puree and mechanical soft diet preparation, as evidenced by the improper handling and preparation of meals during the surveyor's observation.
Removal Plan
- Meal service for Res #9 and Res #16, puree diets, were audited by the Director of Nursing (DON)/Designee to validate they were served the meal at the correct therapeutic menu and pureed consistency.
- An audit was completed by the DON/Designee to ensure required therapeutic diet consistency was provided as ordered by the physician.
- Dietary staff were re-educated by the DON/Designee regarding the requirements of serving therapeutic diets including pureed consistency per physician's orders. Any dietary staff not trained would be trained prior to the beginning of his/her next scheduled shift.
- An audit set up for completion by the Administrator/Designee weekly to ensure dietary staff continue to provide therapeutic diet consistencies per physician's orders including puree consistency.
Failure to Maintain Proper Food Temperatures During Lunch Service
Penalty
Summary
The facility failed to maintain proper food temperatures during lunch service, as observed on 7/9/24. Prior to the meal service, temperatures of various food items were recorded: creamy cheddar macaroni salad at 40 degrees, fruit at 38 degrees, ham salad at 40 degrees, tomato slices at 38 degrees, bacon at 150 degrees, and deviled eggs at 40 degrees. These cold items were removed from the refrigerator just before the temperatures were checked. The bacon was placed on a steam table set to heat, while the cold items were placed on the opposite end of the steam table, which was turned off, with ice packed in the wells. A full-sized sheet pan of deviled eggs was placed on the counter with a cake pan of ice underneath, but during meal service, the sheet pan was moved, leaving half of the deviled eggs over the ice. By the end of the meal service at 12:43 pm, the temperatures of the creamy cheddar macaroni salad, tomato slices, and deviled eggs had risen to 50 degrees, 58 degrees, and 60 degrees, respectively. According to the facility's document on Sanitation and Food Production, cold foods should be maintained at or below 41 degrees Fahrenheit. Staff C, the current Activity Director and former Dietary Manager, confirmed that cold foods should be kept at 41 degrees or colder and that the procedure involves filling the steam table wells with ice for cold foods.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to properly label, date, store, and serve resident foods, as observed during a survey. During an initial walkthrough of the kitchen, several items were found improperly stored in the refrigerator, including a half-empty gallon of chocolate milk with no open date, three bottles of cola without labels or dates, and a bowl of hard-boiled eggs without protective wrap or date. These findings indicate a lack of adherence to food storage policies. During lunch service, Staff B, a cook, was observed handling food improperly. She did not change gloves or perform hand hygiene after handling various items, including the steam table lid, bread, and deviled eggs. Staff B also failed to maintain proper puree texture for a resident's meal, requiring intervention from another staff member. Despite being instructed to discard the improperly pureed macaroni salad, Staff B continued to handle food without changing gloves or washing hands, further compromising food safety. The Registered Dietitian noted that gloves can give a false sense of security, and the facility's policy emphasized the need for glove changes after contamination. Despite recent staff education on food safety, including glove use and food storage, these practices were not followed during the survey. The Dietary Manager was absent during the survey, and oversight was provided by the Activities Director, who confirmed that staff education would continue to address these issues.
Infection Control Deficiencies in Resident Care and Medication Administration
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by multiple observations of staff neglecting hand hygiene and equipment sanitation. During catheter care for a resident with severe cognitive impairment, staff members did not perform hand hygiene between glove changes and handled the catheter drainage bag improperly, contrary to the care plan instructions. Additionally, the staff did not maintain the catheter bag below the bladder level, increasing the risk of infection. In another instance, a registered nurse performed gastric tube site care for a resident with a feeding tube without adhering to proper hand hygiene protocols. The nurse opened supplies before donning gloves and failed to perform hand hygiene between glove changes during the procedure. This oversight in infection control practices was further compounded by the improper handling of mechanical lift equipment, which was not disinfected after use, as observed during the care of two residents requiring assistance with transfers and incontinent care. The facility's medication administration process also demonstrated significant lapses in infection control. A registered nurse failed to perform hand hygiene before and after administering medications, including insulin injections and inhaled medications, to two residents. The nurse also neglected to sanitize a glucometer used for blood sugar testing, which was initially placed in a general area of the medication cart before being moved to a resident-specific section. These actions were inconsistent with the facility's medication administration policy, which mandates hand hygiene at specific points during the process.
Failure to Implement Required Staff Training
Penalty
Summary
The facility failed to implement required training for five staff members, as evidenced by a lack of documentation for completed training in several mandatory topics. The personnel file review, mandatory education calendar, and staff interviews revealed that Staff F, G, H, I, and J did not complete training in communication, Quality Assurance and Performance Improvement (QAPI), compliance and ethics, and behavioral health. Additionally, Staff J did not complete training in resident rights and infection control. The facility's 2024 Mandatory Education calendar listed these topics as required for all staff, yet there was no documentation to confirm the completion of these trainings. The Director of Nursing (DON) confirmed the expectation that all staff should be current with required training.
Failure to Implement Communication Training for Staff
Penalty
Summary
The facility failed to implement communication training for five staff members, as revealed through personnel file reviews, the facility's mandatory education calendar, and staff interviews. The staff members in question, identified as Staff F, G, H, I, and J, were hired between March 1, 2023, and November 16, 2023. Despite the facility's 2024 Mandatory Education calendar listing effective communication as a required course for all staff, there was no documentation indicating that these staff members completed the necessary training. The Director of Nursing confirmed the expectation that all staff should be current with required training, yet the deficiency in communication training was evident.
Failure to Implement Resident Rights Training for Staff
Penalty
Summary
The facility failed to implement resident rights training for one of the five staff members reviewed, specifically Staff J, who was hired on March 28, 2023. The facility's mandatory education calendar for 2024 included topics such as effective communication, resident rights, QAPI, infection control, compliance and ethics, and resident behavioral health, all of which were required for all staff. However, there was a lack of documentation indicating that Staff J had completed the required training in resident rights. During a phone interview on July 11, 2024, the Director of Nursing stated that she expected all staff to be current with the required training. The facility reported a census of 30 residents at the time of the survey.
Failure to Implement Mandatory QAPI Training
Penalty
Summary
The facility failed to implement mandatory Quality Assurance and Performance Improvement (QAPI) training for five staff members, as required by their education calendar. The personnel file review and staff interviews revealed that Staff F, G, H, I, and J did not complete the QAPI training. The facility's 2024 Mandatory Education calendar listed QAPI as a required course for all staff, alongside other topics such as effective communication, resident rights, infection control, compliance and ethics, and resident behavioral health. Despite these requirements, there was no documentation to confirm that the mentioned staff members had completed the necessary QAPI training. The Director of Nursing expected all staff to be current with their required training, but this expectation was not met for the staff reviewed.
Failure to Implement Infection Control Training
Penalty
Summary
The facility failed to implement mandatory infection control training for one of the five staff members reviewed, identified as Staff J. The review of personnel files, the facility's mandatory education calendar, and staff interviews revealed that Staff J, who was hired on March 28, 2023, did not have documentation of completed infection control training. The facility's 2024 Mandatory Education calendar listed infection control as a required course for all staff, along with other topics such as effective communication, resident rights, QAPI, compliance and ethics, and resident behavioral health. During a phone interview, the Director of Nursing stated that all staff were expected to be current with the required training.
Failure to Implement Compliance and Ethics Training
Penalty
Summary
The facility failed to implement compliance and ethics training for five staff members, as revealed through personnel file reviews, the facility's mandatory education calendar, and staff interviews. The staff members in question were hired between March and November 2023, and the facility did not have documentation showing that these staff members completed the required training in compliance and ethics. The facility's 2024 Mandatory Education calendar listed compliance and ethics as a required course for all staff. Despite this requirement, the Director of Nursing stated that all staff were expected to be current with their training, indicating a lapse in ensuring compliance with the training schedule.
Failure to Implement Behavioral Health Training
Penalty
Summary
The facility failed to implement behavioral health training for five staff members, as required by their facility assessment. A review of personnel files, the mandatory education calendar, and staff interviews revealed that Staff F, G, H, I, and J did not complete the necessary training in behavioral health. The facility's 2024 Mandatory Education calendar listed behavioral health as a required course for all staff, alongside other topics such as effective communication, resident rights, QAPI, infection control, and compliance and ethics. Despite these requirements, there was no documentation to confirm that the training had been completed by the staff members in question. The Director of Nursing stated that all staff were expected to be current with their required training.
Failure to Notify Family and Physician of Significant Events
Penalty
Summary
The facility failed to notify the family and/or physician of significant events affecting four residents, including medication errors, a fall, and a significant change in condition. For Resident #26, a medication pass observation revealed that three medications were administered at incorrect dosages, and for Resident #3, one medication was administered at an incorrect dosage. Despite the facility's policy requiring notification of the physician in such cases, the progress notes for both residents did not indicate that the physician had been informed of these errors. Resident #34 experienced a fall, resulting in a bruise on the forehead and pain in the legs, which was not communicated to the family. The resident, who has severe cognitive impairment, was found on the floor after attempting to self-transfer. Although the nurse on call and the physician were notified, the Power of Attorney/Emergency Contact was not informed, as documented in the Risk Management form and progress notes. Resident #24, also with severe cognitive impairment, was found in another resident's room exposed to marijuana, leading to a significant change in condition, including delusions and altered assistance needs. The resident's daughter was informed of the marijuana exposure, but the physician was not updated about the delusions, contrary to the facility's policy. The staff noted the resident's condition was not typical, requiring more assistance than usual, but failed to notify the physician of the change in condition.
Deficiencies in Care Plan Revisions and Updates
Penalty
Summary
The facility failed to fully review and revise the comprehensive care plans for four residents, leading to deficiencies in their care. Resident #26, who had intact cognition and multiple diagnoses including hypertension and deep vein thrombosis, was observed with swollen legs and feet. Despite being on a diuretic medication, the care plan did not include this medication or any related interventions. The interim Director of Nursing acknowledged that care plans should be continuously revised to meet residents' needs, but this was not done for Resident #26. Resident #11, who was totally dependent on staff for care and had intact cognition, was identified as a smoker. However, the comprehensive care plan did not reflect this, despite the resident being listed as a smoker in a facility document. Observations confirmed that Resident #11 required staff assistance for vaping, yet the care plan lacked necessary interventions for smoking safety, as outlined in the facility's smoking policy. Resident #12, with severe cognitive impairment and total dependence on staff, had a care plan that inaccurately described their transfer needs. The care plan stated the resident could transfer with one assist and a walker, but observations and progress notes indicated the use of a mechanical lift for transfers. Additionally, Resident #34, with severe cognitive impairment, had a care plan addressing fall risk but lacked interventions to prevent future falls after an incident. The facility's policy required a full investigation and care plan update after such incidents, which was not completed.
Failure to Conduct Comprehensive Post-Fall Assessment
Penalty
Summary
The facility failed to perform complete and accurate assessments following a fall for a resident with severe cognitive impairment. The resident was found on the floor beside her bed, having attempted to self-transfer, and initially denied any pain or injury. However, the progress notes lacked comprehensive documentation of the fall, including assessments, vitals, or neurological checks. A nurse from the resident's previous facility later observed a bruise on the resident's forehead and reported that the resident complained of leg pain. Subsequently, a family member reported that after the resident was transferred to another facility, x-rays revealed a fractured leg, although the resident had not experienced any falls at the new facility. Hospital records confirmed a right distal femur fracture, with the timeline of the injury undetermined. The Regional Director of Clinical Services indicated that a Risk Management form should have been initiated, followed by a full investigation and intervention in the resident's care plan, with follow-up charting for 72 hours post-incident.
Failure to Document Resident's Appeal Decision for Termination of Skilled Services
Penalty
Summary
The facility failed to document whether a resident wished to appeal the decision to end skilled services, as required by their policy. This deficiency was identified for one resident who was discharged from skilled services. The facility's Social Services Manual mandates that a completed Notice of Medicare Non-Coverage (NOMNOC) form be provided to residents at least two days before the termination of services, allowing them the opportunity for an independent medical review. However, the facility did not maintain documentation of the resident's decision to appeal the termination of services. The Social Services Supervisor confirmed that while residents filled out the form, the documentation regarding their decision to appeal was not retained in the resident's record.
Failure to Timely Complete Significant Change MDS for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) within 14 days for a resident who was placed on hospice care. The clinical record review, staff interview, and facility policy review revealed that the resident was admitted to hospice care with a diagnosis of cerebral atherosclerosis. The MDS assessment indicated a significant change in status, but the completion of the MDS was delayed until 6/5/24, beyond the required 14-day period. The facility's policy mandates that comprehensive assessments, including significant change assessments, must be completed within 14 days after determining a significant change in the resident's status. The Regional Director of Nursing noted that MDS Coordinators are remote and responsible for care planning based on Care Area Assessments (CAA), while daily updates are the responsibility of on-site staff, including a Licensed Practical Nurse or the Director of Nursing.
Inaccurate MDS Assessment for Hemodialysis Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident who was dependent on hemodialysis (HD) treatments. The resident, who had a history of congestive heart failure, chronic kidney disease, end-stage renal disease, and diabetes mellitus, received HD treatments every Monday, Wednesday, and Friday. However, the Admission MDS assessment did not include the resident's HD treatments during the 7-day look-back period, despite documentation in the Electronic Health Record (EHR) indicating the resident received HD on specific dates. The interim Director of Nursing acknowledged that the resident's HD should have been included in the MDS assessment, as required by the facility's policy on the Resident Assessment Instrument (RAI)/MDS.
Failure to Notify PASRR for Resident with Mental Diagnosis
Penalty
Summary
The facility failed to notify the Preadmission Screening and Resident Review (PASRR) program for a resident with a mental diagnosis and medications. The resident was admitted to the facility with a PASRR dated prior to admission, which did not list any mental diagnosis or medications. However, the Minimum Data Sheet (MDS) assessment revealed that the resident was admitted with diagnoses of unspecified dementia with behavioral disturbance, non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. The resident was also admitted with drug classifications of antipsychotic, antianxiety, and antidepressant medications. The facility's social worker confirmed that the only PASRR available for the resident was dated before admission and did not reflect the resident's current medication regimen. The social worker stated that a new PASRR is typically submitted before residents are admitted, but in this case, the medications were incorrect upon admission. The resident was not initially taking antipsychotic medication, but it was started as a trial after admission. The facility's policy requires verification of mental illness or developmental disability diagnoses and contacting the appropriate state agency for a Level II screen, which was not adhered to in this instance.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, leading to deficiencies in care. The resident, who had diagnoses of heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and non-Alzheimer's dementia, required maximum assistance with transfers and was dependent on oxygen. Despite a physician's order for oxygen at 3 liters per minute via nasal cannula, staff were observed transferring the resident without a gait belt and using incorrect oxygen settings. The resident's oxygen tank was set at 2 liters per minute, contrary to the prescribed 3 liters, and the tank was in the red, refill zone, indicating it was empty. Additionally, the care plan directed staff to use a mechanical aid for transfers, which was not followed. Staff were observed transferring the resident manually, without the use of the mechanical aid as required. The interim Director of Nursing confirmed that staff should adhere to doctor's orders and therapy expectations, including the use of mechanical aids when ordered. The facility's policies on transfer techniques and oxygen administration were not followed, contributing to the deficiency in care for the resident.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to provide oxygen per physician orders for a resident, as observed during a survey. The resident, who had diagnoses of heart failure, chronic obstructive pulmonary disease, chronic kidney disease, and non-Alzheimer's dementia, was supposed to receive oxygen at 3 liters per minute (LPM) via nasal cannula continuously, according to a physician's order dated 10/13/23. However, on multiple occasions, the resident was observed receiving oxygen at a lower rate of 2 LPM, and the portable oxygen tank was found in the red, refill zone, indicating it was empty or nearly empty. Staff interviews revealed that the facility did not have a policy for following physician's orders, and the interim Director of Nursing stated that staff should adhere to doctor's orders and therapy expectations. Despite this, the resident's oxygen was not administered as prescribed, with the oxygen concentrator set at 2.5 LPM instead of the ordered 3 LPM. The lack of adherence to the physician's order and the absence of a policy for following such orders contributed to the deficiency identified by the surveyors.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as observed during a medication pass on July 9, 2024. During this observation, a Registered Nurse administered medications to two residents. For the first resident, 19 medications were administered, including Furosemide, Magnesium Oxide, and Fiber Lax. For the second resident, 8 medications were administered, including Calcium. Upon reviewing the Medication Administration Record (MAR) for both residents, discrepancies were found between the medications ordered and those administered. Specifically, the dosages of Furosemide, Magnesium Oxide, Fiber Lax, and Calcium did not match the orders in the MAR. The errors resulted in a medication error rate of 14.8%, significantly exceeding the acceptable threshold of 5%. The Director of Nursing acknowledged that all medication orders should be verified for accuracy against the MAR before administration. The facility's policy on Medication Administration, dated January 2013, outlines the necessary steps for verifying medication orders, including checking the MAR for the correct medication, dose, route, and time, and ensuring the pharmacy prescription label matches the MAR. However, these procedures were not adequately followed, leading to the observed deficiencies.
Failure to Maintain Safe Environment and Proper Transfer Techniques
Penalty
Summary
The facility failed to maintain an environment free from accident hazards, as evidenced by an incident involving Resident #11 and two other residents. Staff F, a registered nurse, discovered Resident #11 in a room with two other residents, where a strong odor of marijuana was present, and two vapes were found on Resident #11's chest. Despite Resident #11 being listed as a smoker in an untitled facility document, the comprehensive care plan did not indicate this. The incident was reported to the local police, and the vapes were identified as containing nicotine and THC, although no charges were filed. Another deficiency was observed when Staff I, a certified nurse aide, transferred Resident #9 without using a gait belt, contrary to the facility's policy. Resident #9, who has diagnoses including heart failure, COPD, chronic kidney disease, and non-Alzheimer's dementia, was assessed as a high fall risk and required maximum assistance with transfers. The care plan directed the use of a mechanical aid for transfers, but Staff I manually transferred the resident without the required equipment, increasing the risk of injury. The facility's policies on smoking and transfer techniques were not adhered to, leading to these deficiencies. The smoking policy required that smoking materials be secured by the facility and designated smoking areas be used, while the transfer policy mandated the use of a gait belt unless otherwise ordered. These lapses in following established protocols contributed to the unsafe conditions observed during the survey.
Infection Control Deficiency in Incontinence Care
Penalty
Summary
The facility failed to adhere to infection prevention standards during incontinence care for two residents. Resident #6, who has short and long-term memory problems and is totally dependent on staff for toileting and personal hygiene, was observed receiving incontinence care without proper hand hygiene practices. Staff did not change gloves or wash/sanitize hands when transitioning from dirty to clean tasks. Additionally, the mechanical lift used during the care was not disinfected after use, contrary to facility policy. Resident #12, who has severe cognitive impairment and is dependent on staff for all care except eating, also received incontinence care without proper infection control measures. Staff failed to change gloves and perform hand hygiene when moving from dirty to clean tasks. Similar to the care provided to Resident #6, the mechanical lift was not disinfected after use. The facility's policy on perineal care, which includes specific steps for hand hygiene and glove changes, was not followed. The Director of Nursing confirmed that staff should perform hand hygiene before and after incontinence care, change gloves when soiled, and clean mechanical lift equipment per policy. The facility's failure to follow these procedures during the care of Residents #6 and #12 resulted in a deficiency related to infection prevention standards.
Failure to Annually Review Facility Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment annually, as required. The last documented review of the facility assessment was dated 4/26/23, and there was no evidence of any review or update conducted between 4/26/23 and 7/10/24. On 7/09/24, the Regional Director of Clinical Services was unable to locate the current facility assessment, and a new assessment had not been completed. The facility's policy, reviewed on 12/19/24, mandates that the facility assessment be reviewed at least annually.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with a hospital, which is necessary to ensure that residents can be promptly transferred to a hospital when they require medical care. This deficiency was identified through a review of facility documents and staff interviews. The facility, which reported a census of 30 residents, lacked documentation of such an agreement with a local hospital. During a phone interview, the Regional Director of Clinical Services confirmed that the facility did not have a transfer agreement in place, although the Administrator had been in contact with a hospital to address this issue. Additionally, the facility did not have a policy regarding hospital transfer agreements.
Failure to Update Care Plan for Resident with COPD
Penalty
Summary
The facility failed to update and revise a resident care plan to reflect non-compliance with physician orders for a resident with COPD. The resident, who had a history of adjusting her oxygen levels, was found to have her oxygen concentrator within reach, allowing her to change the settings herself. Despite multiple staff members and a family member being aware of this behavior, it was not documented in the care plan, and no specific interventions were put in place to prevent the resident from adjusting her oxygen levels. The resident's Minimum Data Set (MDS) indicated that she had intact cognition and required supervision for bed mobility and transfers. The resident had multiple diagnoses, including high blood pressure, renal failure, diabetes mellitus, anxiety, depression, COPD, and chronic respiratory failure with hypoxia. The care plan directed staff to provide oxygen therapy as ordered by the physician but did not include any mention of the resident's non-compliance with oxygen therapy. Interviews with various staff members revealed that the resident frequently complained of shortness of breath and requested her oxygen to be increased. Staff members reported that they were not allowed to adjust the oxygen levels and had observed the resident adjusting it herself. Despite these observations, the care plan was not updated to reflect the resident's behavior, and no additional measures were taken to ensure compliance with the physician's orders. The facility's policy required care plans to be reviewed and revised as needed, but this was not done in this case.
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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