Accura Healthcare Of Knoxville, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Knoxville, Iowa.
- Location
- 606 North Seventh Street, Knoxville, Iowa 50138
- CMS Provider Number
- 165382
- Inspections on file
- 31
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Accura Healthcare Of Knoxville, Llc during CMS and state inspections, most recent first.
A resident with chronic pain, intact cognition, and an order for a 25 mcg/hr fentanyl patch every 72 hours did not receive the ordered controlled medication because the facility failed to properly receive, verify, and document it. Pharmacy records showed one fentanyl patch was delivered and signed for by an RN, but the RN, who was agency staff, only placed the tote in the med room and verbally informed another nurse without opening the package, verifying contents, or completing narcotic documentation. Subsequent staff accounts were unclear, with one LPN reporting only receiving tramadol to place in the Cubex machine, and when an LPN later attempted to apply the fentanyl patch, it was not available. The facility had no narcotic sheet or documentation of the fentanyl patch’s location after delivery, despite the DON’s expectation that nurses verify deliveries against the packing slip and log controlled substances.
A nurse administered both a resident's prescribed medications and another resident's medications in error, leading to the resident becoming unresponsive and requiring emergency intervention, including Narcan and ICU admission for toxic encephalopathy and cardiogenic shock. The resident, who had severe cognitive impairment and multiple comorbidities, was found unresponsive shortly after the error and required intensive medical care.
A resident with moderate cognitive impairment and psychiatric diagnoses became agitated and refused assistance with dressing. An LPN, assisted by two CNAs, continued care despite the resident's distress, used degrading language, and attempted to physically restrain the resident's hands. Staff present reported discomfort with the LPN's actions and language, and the incident was reported to the DON.
Surveyors observed multiple instances of unclean and poorly maintained areas, including detached baseboards, exposed pipes, and persistent urine odors in several rooms and hallways. Staff interviews revealed challenges in controlling odors and maintaining cleanliness, especially for residents with incontinence or uncooperative behaviors. Several residents with complex medical needs were found in rooms with urine-soaked linens, food debris, and dirty furniture, highlighting ongoing environmental deficiencies.
The facility failed to respect residents' rights to self-determination by denying smoking breaks as a form of punishment for behaviors such as yelling or swearing. Five residents reported feeling belittled and dehumanized when their smoking privileges were revoked. Additionally, a resident with Alzheimer's was not allowed to lie down upon request, as staff adhered to a routine schedule rather than the resident's needs. Staff interviews revealed a systemic practice of using smoking breaks as a behavioral management tool, contradicting the facility's policy on residents' rights.
The facility failed to protect residents from mental abuse by denying smoke breaks based on behaviors. Five residents with intact cognition reported feeling belittled and dehumanized when their smoking breaks were revoked for actions like yelling or disagreements with staff. Staff confirmed that smoking was treated as a privilege and could be withheld for inappropriate behaviors, contributing to the deficiency.
A facility failed to ensure a housekeeper completed the required Dependent Adult Abuse Mandatory Reporter Training within the specified timeframe. The housekeeper, who started employment in May, had not completed the training by the due date in November. The Administrator acknowledged the lapse and stated that the Business Office Manager was responsible for tracking training completion. The facility's policy requires initial training within six months of hire and recertification every three years.
A resident with severe cognitive impairment and multiple diagnoses did not receive a required bath or shower on the morning of a scheduled colonoscopy, as per physician orders. The facility lacked specific policies for bathing or following physician's orders, leading to the oversight.
The facility failed to maintain sanitary practices by improperly storing food, with multiple instances of unlabeled and undated food items found in freezers and refrigerators. The facility's policy requires all containers to be labeled and dated, but this was not followed.
The facility failed to employ a certified dietary manager, with the Dining Manager lacking formal training in food safety and nutrition. The Administrator planned to enroll the Dining Manager in a course, and the facility had a contract dietitian present only on Tuesdays. The facility did not have a policy addressing Dietary Manager certification.
Failure to Account for and Document Receipt of Controlled Fentanyl Patch
Penalty
Summary
The facility failed to maintain a system to properly receive and account for a controlled substance (fentanyl patch) prescribed for a resident with chronic pain syndrome, seizure disorder, and depression. The resident’s MDS showed intact cognition with a BIMS score of 15/15, and the MAR contained an order for a 25 mcg/hr fentanyl transdermal patch to be applied every 72 hours for chronic pain. A pharmacy packing slip documented that one fentanyl patch was delivered and signed for by an RN on the evening of 10/25/25. The facility’s policy on controlled substances required proper handling, storage, disposal, and record keeping, including verifying medications against the packing slip, logging them, and keeping controlled substances double locked. However, there was no narcotic sheet documenting receipt of the fentanyl patch, and the facility lacked documentation of the patch’s location after it was signed in. Staff interviews and record review showed multiple breakdowns in the receipt and logging process. The RN who signed for the delivery stated she was agency staff, did not know she needed to open the package, and only placed the tote in the medication room and verbally informed another nurse that medications had arrived, without verifying contents or documenting the controlled substance. Other staff gave inconsistent or limited accounts of handling the delivery bag and medications, and one LPN reported only receiving tramadol from another nurse to place in the Cubex machine. When an LPN later attempted to apply the fentanyl patch for the resident, it was not available, and a subsequent search did not locate it. The DON stated that nurses were expected to sign in medications, verify them against the packing slip, and add a log sheet for controlled substances, but this process was not followed for the fentanyl patch, resulting in the missing narcotic and lack of required documentation.
Medication Administration Error Resulting in ICU Admission
Penalty
Summary
A medication administration error occurred when a nurse gave a resident both her prescribed morning medications and, in error, administered another resident's medications as well. The nurse had completed the initial medication pass for the resident, who had severe cognitive impairment and multiple diagnoses including stroke, kidney disease, diabetes, dementia, anxiety, and depression. Shortly after, the nurse prepared medications for a different resident but mistakenly called out to the first resident, who responded by opening her mouth, and the nurse administered the second set of medications to her. The error was realized approximately five minutes later when the nurse reviewed the medication records. Following the administration of the incorrect medications, the resident became unresponsive within minutes. Staff assessed the resident, notified the on-call provider, and were instructed to monitor vital signs and provide fluids. The resident was found unresponsive to verbal and physical stimuli, prompting immediate emergency intervention, including administration of Narcan and calling 911. Emergency medical services arrived, and the resident was transported to the hospital, where she was admitted to the ICU with diagnoses of toxic encephalopathy and cardiogenic shock secondary to the medication error. The resident's medical record indicated she had no swallowing disorder and was on multiple medications, including antianxiety, antidepressant, anticoagulants, hypoglycemics, and anticonvulsants. The care plan directed staff to administer medications as ordered and monitor for side effects. The incident resulted in the resident requiring intensive medical intervention, including ICU admission, and she subsequently developed severe dysphagia. Interviews with staff and family confirmed the sequence of events and the impact of the medication error.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A resident with moderate cognitive impairment and multiple psychiatric diagnoses, including paranoid schizophrenia, delusional disorders, anxiety disorder, and major depressive disorder, was dependent on staff for activities of daily living (ADLs). During an incident, an LPN with nearly 30 years of experience, along with two CNAs, attempted to assist the resident with dressing. The resident became agitated, refused assistance, and exhibited physical resistance by yelling, hitting, and biting staff. Despite the resident's distress and refusal, the LPN continued to attempt care and responded by calling the resident degrading names and using offensive language. Staff interviews confirmed that the LPN used demeaning language in the resident's presence and attempted to physically restrain the resident's hands instead of disengaging from the situation. Other staff present during the incident reported feeling uncomfortable with the LPN's actions and language, and both CNAs reported the incident to the Director of Nursing (DON) on the same day. The LPN later confirmed using degrading words, though she believed the resident did not hear them. The administrator stated that staff are expected to step away and allow time before reattempting care if a resident refuses, and to try a different staff member if needed. The facility did not have a specific policy for Resident Rights/Dignity but stated they followed regulations and standards of care.
Failure to Maintain Clean, Orderly, and Odor-Free Environment
Penalty
Summary
The facility failed to maintain a clean, orderly, and well-repaired environment, with multiple observations of detached or damaged baseboard guards in resident bathrooms and hallways, exposing boiler pipes and leaving unfinished, jagged walls. Maintenance staff relied on other staff to report issues through an app, and several maintenance concerns were identified but not yet addressed at the time of the survey. These environmental deficiencies were directly observed in specific rooms and common areas. Persistent urine odors were noted in several rooms and hallways, despite regular cleaning efforts. Housekeeping staff acknowledged that some furniture, such as bed stands, were in poor condition and could not be adequately cleaned, with some items described as dirty and rusty. Staff interviews revealed ongoing challenges in controlling odors, particularly in rooms with residents who were incontinent or uncooperative with care, and there was confusion regarding responsibility for cleaning certain items like wheelchairs and bed stands. Multiple residents with significant medical histories, including Alzheimer's disease, dementia, stroke, and incontinence, were observed in unclean environments. Specific observations included residents lying in beds with urine-soaked linens, food debris on sheets and floors, dirty dishes left in rooms, and dark, unkempt living spaces. In some cases, residents refused removal of dirty items, and staff reported difficulties in maintaining cleanliness due to resident behaviors and the condition of facility furnishings.
Facility Fails to Honor Residents' Rights to Self-Determination
Penalty
Summary
The facility failed to honor residents' rights to make choices about significant aspects of their lives, specifically regarding smoking breaks and resting schedules. Five residents who were smokers reported that their smoking breaks were denied as a form of punishment for behaviors such as yelling, swearing, or being disruptive. These actions were documented in the residents' care plans and health status notes, indicating that smoking was considered a privilege that could be revoked by staff for behavioral issues. Residents expressed feelings of belittlement, anger, and dehumanization when their smoking breaks were taken away. Additionally, the facility did not allow a resident with Alzheimer's and dementia to lie down upon request, instead making him wait until after supper. This decision was based on a routine schedule rather than the resident's immediate needs, as confirmed by staff interviews. The facility's policy on residents' rights stated that residents should have the right to make choices about their activities and schedules, including sleeping and waking times, which was not adhered to in this case. Interviews with staff and the administrator revealed a systemic practice of using smoking breaks as a behavioral management tool, which contradicted the facility's policy on residents' rights. Staff members, including a Registered Nurse and a Nurse Specialist, justified the denial of smoking breaks as a necessary measure to manage resident behavior, despite acknowledging that residents have rights. The administrator confirmed that this practice had been in place for three years, indicating a long-standing issue with respecting residents' rights to self-determination.
Facility Fails to Protect Residents from Mental Abuse by Denying Smoke Breaks
Penalty
Summary
The facility failed to ensure residents were free from mental abuse by denying smoke breaks based on resident behaviors. This deficiency was identified for five residents who were smokers and had intact cognition, as indicated by their Brief Interview for Mental Status (BIMS) scores. The residents reported feeling belittled, angry, and dehumanized when their smoking breaks were taken away as a consequence of their behaviors, such as disagreements with staff, yelling, or using derogatory language. The facility's policy allowed staff to deny smoking privileges for safety concerns, but staff interviews revealed that smoking breaks were also withheld as a form of behavior management. Staff members, including CNAs and an RN, confirmed that smoking breaks were taken away when residents exhibited behaviors such as yelling, swearing, or being disruptive. The facility administrator and a nurse specialist also stated that smoking was considered a privilege and could be revoked for inappropriate behaviors. The report highlights specific instances where residents were denied smoking breaks, leading to feelings of punishment and mental abuse. For example, one resident was denied a smoke break after yelling in the hallway, and another was told they could not smoke after an outburst directed at staff. These actions were consistent with the facility's practice of using smoking breaks as a behavioral control measure, which contributed to the deficiency in protecting residents from mental abuse.
Failure to Complete Mandatory Reporter Training
Penalty
Summary
The facility failed to ensure that a staff member, identified as Staff B, met the requirements for Dependent Adult Abuse Mandatory Reporter Training. Staff B, a housekeeper, began employment on 5/29/24, and was required to complete a 2-hour training course on dependent adult abuse identification and reporting by 11/29/24. However, a review of records revealed that Staff B had not completed this mandatory training by the due date. During an interview on 1/29/25, the Administrator acknowledged the oversight and confirmed that Staff B was in the process of completing the training. The Administrator also stated that it was the responsibility of the Business Office Manager to track training completion dates and notify the Administrator when staff were due for training. The facility's policy, updated on 10/19/22, mandates that all employees complete the initial training within six months of hire and a 1-hour recertification every three years thereafter.
Failure to Follow Pre-Op Bathing Orders for Resident
Penalty
Summary
The facility failed to ensure that staff followed physician pre-operative orders for a resident scheduled for a colonoscopy. The resident, who had severe cognitive impairment and required extensive assistance with personal care, was supposed to receive a bath or shower on the morning of the procedure as per the physician's orders. However, there was no documentation indicating that this was done on the day of the procedure. Instead, the resident was found with wet and clumpy powder in her groins upon arrival for the procedure, suggesting that the pre-operative hygiene instructions were not followed. The resident's medical history included ulcerative colitis, Alzheimer's disease, anxiety disorder, and depression, and she was dependent on staff for bathing and personal hygiene. Despite the facility's expectation that staff adhere to physician orders and standards of care, the lack of a specific policy for bathing or following physician's orders contributed to the oversight. The administrator acknowledged the expectation for staff to provide the necessary care but confirmed the absence of formal policies to guide staff actions in this regard.
Improper Food Storage Practices
Penalty
Summary
The facility failed to maintain sanitary practices by improperly storing food, as observed during kitchen inspections. On multiple occasions, surveyors found various food items in the facility's freezers and refrigerators that were unlabeled and undated. Specific findings included unlabeled bags of meat, chopped meat, dough-like slices, and other food items in different units of the kitchen. Additionally, a metal pan with casserole-like contents and a used ladle stored on top was found in the refrigerator, along with an undated plastic tub of sour cream and other unlabeled items. The dry goods room also contained an opened, undated bag of bread crumbs and unlabeled plastic containers with cereal-like contents in a cabinet. During a follow-up observation, similar issues were noted, including unlabeled and undated bags of various food items in the freezers and refrigerators. The facility's policy on food storage, dated 2021, mandates that all containers or storage bags must be legible, covered, and accurately labeled and dated. However, these guidelines were not followed, leading to the identified deficiencies. The Administrator confirmed that all stored food should be dated and labeled, indicating a lapse in adherence to the facility's own policies.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service by not having a certified dietary manager. The facility, with a census of 51 residents, had a Dining Manager who was not certified and had no formal coursework training in food safety and nutrition. The Dining Manager had only 1.5 years of experience as an assistant dietary manager at another facility. The Administrator planned to enroll the Dining Manager in a six-month course starting in April. The facility had a contract dietitian who was present only on Tuesdays. The facility did not have a policy addressing Dietary Manager certification, and the Facility Assessment indicated that a Dietary Supervisor should be involved in completing the assessment, with an average daily resident census of 47.
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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