Accura Healthcare Of Lake City, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake City, Iowa.
- Location
- 1409 West Main Street, Lake City, Iowa 51449
- CMS Provider Number
- 165082
- Inspections on file
- 23
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Accura Healthcare Of Lake City, Llc during CMS and state inspections, most recent first.
Surveyors found that a resident with COPD and severe cognitive impairment received oxygen at a higher flow rate than ordered, with documentation and observations showing use of 2 L/min instead of the prescribed 1.5 L/min via nasal cannula. During med pass, a CMA administered pain and diuretic medications to two cognitively intact residents but left before confirming the medications were swallowed. For another cognitively intact resident with atrial fibrillation, the CMA removed Tylenol tablets from a non-original container stored in a med cart drawer and handled the pills with bare fingers, contrary to infection control and medication storage standards.
The facility failed to provide adequate staffing to complete restorative programs and scheduled baths as care planned. Three residents with conditions including heart failure, MS, hemiplegia, dementia, COPD, diabetes, and mobility limitations had restorative nursing plans calling for daily or near-daily AROM and PROM exercises 3–6 days per week, but documentation showed these services were provided only a few times over a month or once weekly over several weeks. A CNA assigned as the restorative aide reported being pulled from restorative duties to work the floor when the facility was short-staffed. Additionally, three residents who required varying levels of assistance with bathing and were scheduled for two baths per week received only one bath during certain weeks. A CNA stated they had been working short and could not confirm that all scheduled baths were completed, and the DON acknowledged a staffing crisis.
Staff reported that during a recent noon meal featuring apricot chicken, several residents were served poultry that appeared pink, red, or “bleeding,” and one CNA discovered raw chicken thighs while preparing a plate, with some residents stating they received bloody chicken and did not eat it. During observation of a separate noon meal service, staff delivering trays to rooms found that hot food items on heated plate warmers were below the facility’s required 135°F, with meat temperatures recorded around 130°F and as low as 126°F, and side dishes also below standard, indicating failure to ensure food was fully cooked and maintained at safe serving temperatures.
Surveyors found unsanitary conditions in the kitchen, including food debris, residue on equipment, and undated food items in both the refrigerator and pantry. Despite established cleaning schedules and policies requiring food to be dated when opened, staff did not consistently follow these procedures, resulting in improper food storage and preparation practices.
The facility did not notify the responsible parties for two residents when there were significant changes in their conditions, including a hospital admission for pneumonia and a positive Influenza A diagnosis. In both cases, families were not informed in a timely manner, and documentation of notification was lacking, despite facility policy and staff expectations.
Two residents experienced deficiencies in care when staff failed to follow physician orders and professional standards. One resident with a history of falls and on anticoagulant therapy was not consistently offered or documented as refusing ER evaluation after falls with possible head injury, and staff did not update or follow dietary and swallowing precautions as recommended by speech therapy. Another resident with a UTI did not receive timely initiation of prescribed antibiotics after lab results, and there was a lack of documentation regarding physician notification and follow-up.
Two residents requiring staff assistance for bathing did not receive scheduled baths as documented in their care plans, with records showing missed and insufficient bathing over a 30-day period. Both residents reported receiving fewer baths than scheduled, and facility staff were unable to provide documentation of refusals or additional efforts to encourage bathing. The facility lacked a formal bathing policy and had inconsistencies in documentation and understanding of bathing schedules.
A resident at risk for pressure ulcers, with multiple comorbidities and requiring significant assistance with mobility, developed a stage 2 pressure ulcer on the right heel. The care plan did not include individualized interventions for pressure ulcer prevention, and there was no documentation of risk management or root cause analysis, despite facility policy requiring such measures.
A resident with multiple diagnoses and a history of falls was not consistently provided with care plan interventions intended to reduce fall risk, such as keeping the room door ajar for monitoring and maintaining the bed in a low position. Observations showed these interventions were not followed, and the resident experienced several falls. Staff interviews indicated some CNAs were unaware of the care plan details, contributing to the deficiency.
A resident with a history of frequent falls and diagnoses including dementia and hallucinations experienced multiple unwitnessed falls, one resulting in a hand fracture, due to the facility's failure to implement timely and effective interventions and provide adequate nursing supervision. Incident reports and root cause analyses were often not completed as required, and interventions were inconsistently applied or delayed, despite the facility's policy mandating prompt reporting and investigation of such events.
A resident with moderate cognitive impairment and swallowing difficulties choked on a sandwich in the dining area, with only a noncertified nurse aide present. The aide was unable to perform the Heimlich maneuver effectively and could not summon help due to a malfunctioning walkie talkie. The delay in assistance led to the resident experiencing severe respiratory distress and ultimately passing away from cardiac arrest related to the choking incident.
The facility failed to maintain an effective pest control program, leading to a mouse infestation affecting multiple residents. A resident was startled by a mouse in her room, causing her to fall. Staff confirmed ongoing issues, with mice seen in several rooms and potential entry points identified. The facility's administrator was aware of the problem and had changed pest control companies.
A facility failed to provide sufficient nursing staff with appropriate training, leading to a choking incident during a meal. A Training CNA, lacking state-approved training, was unable to perform the Heimlich maneuver effectively on a resident. The walkie-talkie failed, delaying assistance by approximately three minutes. The facility's job description required supervision for aides in training, which was not provided during this incident.
The facility failed to ensure a nurse aide, Staff A, was properly trained and competent according to state requirements. Staff A's file lacked evidence of training by a state-approved program or enrollment in a CNA class, despite having worked as a Training CNA at another facility. The facility's administrator noted that nurse aides could work for up to four months if they demonstrated skills and competencies with an RN, which Staff A had done at her previous facility. However, her file did not show enrollment in a state-certified CNA course, leading to the deficiency.
A facility failed to maintain a proper drug reconciliation system, resulting in a missing Methadone pill for a resident. The discrepancy was discovered during a shift change narcotic count, where a CMA noticed the count was off. The overnight nurse, who had access to the medication cart, was unaware of the pill's whereabouts. An internal investigation revealed lapses in the documentation process, with missing signatures on the controlled drug count record.
A resident with moderately impaired cognition and multiple health conditions experienced an unwitnessed fall, but the facility failed to document follow-up fall assessments and neurological checks. The DON acknowledged a late entry in the progress notes and the absence of a specific neurological policy, leading to the omission of necessary assessments.
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision. A broken laundry room door allowed 11 mobile residents access to hazardous chemicals. A resident with moderate cognitive impairment was found near the laundry room door on multiple occasions. Hazardous chemicals were stored openly, posing a significant safety risk.
A facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) after a resident reported that a CNA was rough with them during a brief change. The facility conducted an internal investigation but did not report the incident, concluding there was no harm and the resident did not feel the CNA's actions were intentional abuse.
The facility failed to ensure timely response to resident call lights, with two residents reporting waits longer than 15 minutes. Staff interviews indicated insufficient staffing, particularly on the 2pm-10pm shift, contributing to the delays.
Failure to Follow Oxygen Orders and Medication Administration Standards
Penalty
Summary
Surveyors identified multiple failures to follow professional standards of quality related to oxygen administration, medication administration, infection control, and medication storage. One resident with severe cognitive impairment and chronic obstructive pulmonary disease had a physician order and care plan for oxygen at 1.5 L/min via nasal cannula. However, clinical records, including weights and vitals and progress notes, repeatedly documented the resident receiving oxygen at 2 L/min on several occasions. During observation, the resident was seen in bed on 1.5 L/min via concentrator, but later in the dining room on 2 L/min via a portable tank, inconsistent with the ordered 1.5 L/min. Facility leadership could not explain why oxygen was documented or set at 2 L/min and acknowledged that an agency CNA had turned the oxygen up to 2 L/min. Surveyors also observed failures in medication administration and infection control practices. A cognitively intact resident with pain was given ibuprofen 200 mg by a CMA, who walked away before confirming the resident swallowed the medication. Another cognitively intact resident on diuretic therapy was given Coenzyme Q10 and Lasix 40 mg by the same CMA, who again left the room before observing ingestion. For a third cognitively intact resident with atrial fibrillation, the CMA prepared PRN Tylenol by taking two round white tablets from a clear plastic cup stored in the top drawer of the med cart, handling the tablets with bare fingers and not from the original container. The DON, ADON, and Administrator confirmed that staff should observe residents swallowing medications, should not touch medications with bare hands, and should store medications in their original containers until administration, as required by the facility’s medication administration policy.
Insufficient Staffing Leading to Missed Restorative Services and Scheduled Baths
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to complete restorative nursing programs as planned for three residents. One resident with heart failure, atrial fibrillation, asthma, arthritis, and advanced age had a care plan revised in September that called for daily upper extremity exercises with Thera bands or light weights, 3–6 days per week, but documentation showed restorative exercises were completed only five times in the previous 30 days. A second resident with multiple sclerosis, moderate cognitive impairment, and dependence on staff for transfers had a care plan for active range of motion to the neck and shoulders with specified repetitions and sets, but the restorative program was documented as completed only four times in the previous 30 days. A third resident with hemiplegia, moderate cognitive impairment, and functional limitations in range of motion of one side of the body had a care plan for daily active and passive range of motion to upper and lower extremities, 3–6 days per week, yet the point-of-care records showed restorative services were provided only once per week over multiple weeks. The report further documents that the certified nursing assistant assigned as the restorative aide stated she tried to complete all required tasks but, when the facility was short-staffed, she was pulled from restorative duties to work on the floor. The facility’s Restorative Program Process, updated in October, stated that its purpose was to ensure residents achieved and maintained their highest level of function and that licensed nurses would monitor daily restorative documentation and follow up with staff as needed. Despite this written process, the recorded frequency of restorative interventions for the three residents did not match the planned frequency outlined in their care plans and task lists. The deficiency also includes the facility’s failure to ensure three residents received at least two baths per week as planned. One resident with severe cognitive impairment, COPD, osteomyelitis, and diabetes with neuropathy was care planned to receive assistance of one to two staff for bathing and was documented as dependent for baths, with records showing two baths per week except for one week when only one bath was provided. A second resident with no cognitive impairment, diabetes, muscle weakness, and gait abnormalities required supervision or touching assistance with bathing and was care planned for bathing assistance of one, but documentation showed only one bath during a particular week instead of the usual two. A third resident with severe cognitive impairment, non-Alzheimer’s dementia, and limited mobility required partial to moderate assistance and was care planned for assistance of one with bathing, yet records showed only one bath during a specified week. A CNA reported that staffing had been short, that most residents were scheduled for two baths per week, and that with increased use of agency staff she could not confirm whether all baths were being completed. The DON later stated they were experiencing a staffing crisis and had recently admitted a new resident.
Undercooked Poultry and Improper Hot Food Holding Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures. Menu review showed apricot chicken was served on a Wednesday noon meal. Multiple staff members, including an LPN and several CNAs, reported that about one to two weeks prior, residents had been served chicken that was not fully cooked, with meat described as still pink or red and, in one case, “bleeding.” One CNA reported discovering raw chicken thighs while removing meat from the bone for a resident and stated that other plates contained similarly undercooked chicken. Staff reported that some residents received bloody chicken and did not eat it. The Administrator and Dietary Manager later identified the meal as the apricot chicken menu item and stated that when they checked the remaining chicken at kitchen tear-down time, it appeared cooked but contained veins that might have been misinterpreted as blood. In addition to concerns about undercooked chicken, observations during a noon meal service showed that hot foods were not consistently maintained at or above the facility’s required hot-holding and serving temperature of 135°F. Trays for residents in their rooms were assembled using heated plate warmers and transported on two carts. When one staff member checked a tray upon reaching a resident’s room, the meat temperature was 130.7°F and the potatoes were 133°F. Shortly afterward, another cart’s meat temperature was measured at 126°F. These temperatures were below the facility’s policy requirement that all hot food items be cooked to appropriate internal temperatures and held and served at a minimum of 135°F.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
Surveyors observed multiple instances of unsanitary conditions and improper food storage practices in the facility's kitchen. During an initial kitchen tour, they noted a milk cooler with dried liquid residue, smudge prints on the freezer and refrigerator doors, and crumbs or food debris at the bottom of both refrigerators and freezers. Additional findings included a steam table with a brown, crusty dried substance and a warmer with crumbs and food debris on its bottom. Several food items, such as an open container of ranch salad dressing in the refrigerator and packages of country gravy, dried pudding, and ranch dressing seasoning in the pantry, were found without open dates. Review of facility policies revealed that staff are required to maintain cleanliness and sanitation in food service areas through adherence to a comprehensive cleaning schedule, and all food items must be properly dated and stored to prevent contamination. Interviews with the Certified Dietary Manager confirmed the existence of daily, weekly, and monthly cleaning schedules and checklists, as well as the expectation for staff to date food packages when opened. Despite these policies, the observed conditions and undated food items indicated that staff did not consistently follow established procedures for cleaning and food storage.
Failure to Notify Family of Resident Condition Changes and Hospitalization
Penalty
Summary
The facility failed to notify the family or responsible party of significant changes in condition for two residents. One resident, who was cognitively intact and independent in mobility, developed a productive cough, abnormal lung sounds, a high fever, and low oxygen saturation. The resident was subsequently diagnosed with pneumonia and admitted to the hospital. There was no documentation that the resident's niece and power of attorney (POA) was notified of the change in condition or the hospital transfer. The niece/POA later contacted the facility, upset about not being informed, and the resident confirmed she wanted her POA notified of such events. Another resident, with diagnoses including non-traumatic brain dysfunction and dementia but no cognitive impairment, tested positive for Influenza A. The family was not notified of the positive result and only learned of it upon visiting, when they found precaution signs and personal protective equipment outside the resident's room. Facility records did not show any documentation of family notification regarding the positive influenza result. Staff interviews confirmed that the expectation was for families to be notified promptly, but this did not occur.
Failure to Follow Physician Orders and Professional Standards of Care
Penalty
Summary
The facility failed to provide care and services according to accepted standards of clinical practice for two residents. For one resident with a history of falls, Parkinson's disease, atrial fibrillation, and use of anticoagulant medication, there were multiple incidents where the facility did not follow physician orders and care plan directives after falls, particularly those involving potential or actual head injuries. Documentation was lacking regarding whether the resident or his wife was offered or refused emergency room evaluation after unwitnessed falls with possible head injury, despite clear physician recommendations and care plan instructions to do so. Additionally, there was a failure to document and follow up on the status of the resident's anticoagulant medication after it was held due to a subdural hematoma, with no further action or physician guidance documented for an extended period. The same resident also experienced deficiencies in the implementation of speech therapy recommendations. Despite clear orders and therapy recommendations for a modified diet and no use of straws due to coughing and swallowing difficulties, staff continued to provide straws and did not update the care plan or CNA Kardex to reflect these restrictions. Observations confirmed that the resident was given straws with liquids and whole pills without the recommended modifications, resulting in episodes of coughing during medication administration and meals. Staff were observed to be unaware or inconsistent in following the therapy recommendations, and the care plan was not updated to reflect the current dietary and swallowing precautions. For another resident with a history of urinary tract infections, the facility failed to promptly act on laboratory results and physician orders. After a urine culture indicated a significant infection, there was no documentation that the results were received or communicated to the physician in a timely manner. The prescribed antibiotic was not started until the evening of the day after the order was received, despite the medication being available in the facility's emergency kit. The facility's policy required prompt notification and follow-up with the physician for abnormal lab results, but this was not documented or carried out as required.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide adequate bathing assistance to two residents who required staff support for activities of daily living. One resident, with diagnoses including peripheral vascular disease, diabetes mellitus, non-Alzheimer's dementia, and an unstageable pressure ulcer, was scheduled for two baths per week but only received a bath once a week according to both facility documentation and the resident's own report. The clinical record lacked documentation of refusals or attempts to encourage or offer additional bathing, and there was no evidence of other efforts to meet the resident's scheduled bathing needs. Another resident, with a history of diabetes mellitus, cerebrovascular accident, psychotic disorder, anxiety, and depression, required substantial assistance for bathing and was dependent on staff for transfers. This resident was also scheduled for two baths per week but received only four baths in a 30-day period, with documentation showing missed and refused baths but lacking evidence of re-approach or encouragement as directed in the care plan. Both residents reported receiving fewer baths than scheduled, and staff interviews confirmed a lack of documentation and understanding regarding bathing schedules and refusals. The facility did not have a formal bathing policy and relied on regulations and standard practice.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement appropriate interventions to prevent the development of a stage 2 pressure ulcer on the right heel of a resident who was identified as being at risk for pressure ulcers. The resident had diagnoses including hip fracture, peripheral vascular disease, and renal insufficiency, and required substantial to maximal assistance with mobility and transfers. The resident's baseline care plan did not include any interventions specifically aimed at preventing pressure ulcers, despite the resident's risk status and the presence of a pressure reducing device on the bed. A skin assessment later identified a stage 2 pressure ulcer on the resident's right heel. Facility policy required evidence-based, individualized interventions for residents at risk for pressure injuries, with documentation in the care plan and communication to staff. However, the care plan lacked such interventions, and there was no documentation of risk management, incident review, or root cause analysis related to the pressure ulcer. The DON confirmed that interventions were not put in place and that the area was thought to have resulted from the resident's shoe, but no further investigation or preventive measures were documented.
Failure to Implement Fall Prevention Interventions per Care Plan
Penalty
Summary
The facility failed to implement care plan interventions designed to reduce the risk of falls for a resident with multiple medical conditions, including hypertension, CVA, non-Alzheimer's dementia, Parkinson's disease, seizure disorder, and paroxysmal atrial fibrillation. The resident's care plan identified them as being at risk for injury related to falls and included specific interventions such as keeping the room door ajar for closer monitoring and ensuring the bed was in the lowest position when occupied. However, clinical record review showed that these interventions were not consistently followed, as evidenced by repeated observations of the resident's door being closed and the bed not in the low position, contrary to the care plan directives. Additionally, the resident experienced seven falls over a four-month period, further indicating that the care plan interventions were not effectively implemented. Staff interviews revealed a lack of awareness among some CNAs regarding the care plan and kardex, which contributed to the failure to carry out the prescribed interventions. The facility's policy required that qualified staff be notified of their responsibilities for implementing care plan interventions, but this was not consistently done, leading to the deficiency.
Failure to Prevent Repeated Falls and Inadequate Supervision
Penalty
Summary
The facility failed to implement effective interventions and provide adequate nursing supervision to prevent accidents and injuries from falls for a resident with a known history of repeated falls. Over a three-month period, the resident experienced thirteen falls, including an unwitnessed fall that resulted in a fracture to the left hand. Despite the resident's identified risk for falls, the care plan interventions were often delayed or insufficient, with some interventions not implemented until after further assessment or review by other disciplines, such as medication reviews or physical therapy evaluations. In several instances, the facility did not complete required incident reports or root cause analyses following falls or other significant incidents. The resident's clinical records indicated no cognitive impairment, but diagnoses included non-traumatic brain dysfunction, non-Alzheimer's dementia, and hallucinations. The resident was independent in most mobility tasks but required supervision for toileting and was frequently incontinent of urine. The incident reports and progress notes documented multiple unwitnessed falls in various locations, including the resident's room, hallway, and bathroom. Interventions such as encouraging the use of gripper socks, reviewing medications, and replacing furniture were inconsistently applied, and in some cases, no immediate interventions were put in place following incidents. Staff interviews revealed inconsistencies in the implementation and documentation of frequent checks and supervision, particularly regarding the resident's wandering behavior and entry into other residents' rooms. The facility's policy required all accidents and incidents to be reported, investigated, and reviewed through the QAPI process, with specific procedures for completing incident reports and root cause analyses. However, the facility failed to adhere to these policies in several instances, as evidenced by missing incident reports and delayed or inadequate interventions following repeated falls and other incidents involving the resident.
Inadequate Supervision During Choking Incident
Penalty
Summary
The facility failed to provide adequate supervision during a choking incident involving a resident with moderate cognitive impairment and a history of swallowing difficulties. The resident, who was on a mechanical soft diet with honey thick liquids, choked while eating a sandwich in the assisted dining area. At the time of the incident, the only staff present was a noncertified nurse aide who was unable to perform the Heimlich maneuver effectively and could not summon help due to a malfunctioning walkie talkie. The noncertified nurse aide attempted to assist the choking resident by providing back thrusts, but these efforts were unsuccessful. The aide's inability to perform the Heimlich maneuver and the failure of the walkie talkie to function properly delayed the arrival of additional help. A dietary aide eventually responded to the aide's calls for help and sought further assistance from the nursing staff. By the time the licensed practical nurse arrived and performed abdominal thrusts, the resident had already experienced significant respiratory distress. The resident's condition deteriorated rapidly, with symptoms including cyanosis, low oxygen saturation, and acute respiratory failure. Despite the efforts of the nursing staff and emergency medical technicians, the resident was unable to recover and ultimately passed away due to cardiac arrest related to the choking incident. The facility's failure to ensure appropriately trained staff were present and equipped to handle such emergencies contributed to the severity of the incident.
Removal Plan
- The Administrator initiated staff education to ensure all nursing staff are carrying a functioning walkie talkie.
- All nursing staff will be educated on the requirement to ensure licensed nurses or certified nurse aides are the only staff assisting residents during meals.
- There are no uncertified nurse aides on the nursing schedule.
- Staff A is no longer employed at the facility.
- The DON/Administrator and/or designee will audit staff for compliance with walkie talkie usage.
- The DON/Administrator and/or designee will audit the nursing daily schedule sheets to ensure licensed/certified staff are scheduled.
- Any concerns will be reported to the Administrator and addressed in facility QA.
Mouse Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a mouse infestation that affected multiple residents. A resident reported seeing a mouse in her room in November, which startled her and caused her to fall. She later encountered another mouse caught in a sticky trap. Staff confirmed the presence of mice, with a CNA stating that the infestation had been ongoing and residents and family members had raised concerns. The LPN also acknowledged the issue, noting that a mouse was seen the previous day. The pest control report dated January 7, 2025, documented active rodent activity in nine rooms, with four rooms having potential entry points that needed sealing. The maintenance staff confirmed that the pest control company had identified areas where mice could enter and had begun sealing these points. The facility's administrator was aware of the infestation and had recently changed pest control companies, indicating ongoing efforts to address the issue.
Inadequate Training and Supervision During Meal Leads to Choking Incident
Penalty
Summary
The facility failed to ensure sufficient nursing staff with appropriate training to provide supervision during a meal, as evidenced by the incident involving Staff A. Staff A, who was working as a Training Certified Nursing Assistant (CNA), lacked training by a state-approved program or enrollment in a CNA class. Her personnel file indicated previous experience in a restaurant and a short tenure at another facility as a Training CNA. During a meal, Staff A was feeding a resident when another resident began choking. Despite her attempts to perform the Heimlich maneuver, she was unable to do so effectively due to her inability to fit her arms around the resident. She called for help, but the walkie-talkie did not work, leading to a delay in assistance. The incident occurred in the dining room, where Staff A was the only staff member present at the time. The resident who was choking did not lose consciousness, but the situation was not resolved until other staff arrived approximately three minutes later. The facility's job description for an Aide in Training indicated that such staff should perform duties under direct supervision, yet Staff A was left unsupervised during this critical incident. The facility's failure to provide adequate training and supervision contributed to the deficiency noted in the report.
Failure to Ensure Proper Training and Competency of Nurse Aide
Penalty
Summary
The facility failed to ensure that a nurse aide, referred to as Staff A, was properly trained and competent according to state requirements. Staff A's personnel file indicated that she had worked as a Training CNA at another facility from August 2024 to September 2024 and had previously worked in a restaurant from July 2021 to July 2024. Although Staff A signed a job description for a Certified Nursing Assistant (CNA) and had a CNA/Nurse Aide-Skills and Competency checklist from her previous employment, her personnel file lacked evidence of training by a state-approved program or enrollment in a CNA class. The facility's administrator stated that nurse aides could work for up to four months if they had demonstrated skills and competencies with a Registered Nurse (RN), which Staff A had done with the Director of Nursing (DON) at her previous facility. However, the previous facility had closed, and Staff A, along with others, transferred to the current facility. The facility's job description for an Aide in Training (CNA Scholarship) indicated that candidates would be enrolled in a state-certified CNA course either before joining the team or after a predetermined period of non-certified work. Despite this, Staff A's file did not show enrollment in such a course, leading to the deficiency finding.
Failure in Drug Reconciliation Leads to Missing Methadone Pill
Penalty
Summary
The facility failed to maintain a system of drug reconciliation, resulting in a missing Methadone pill for one resident. The incident was discovered during a narcotic count when a Certified Medication Assistant (CMA) noticed a discrepancy in the Methadone count for a resident, with one 2.5 mg tablet missing. The discrepancy was identified during the shift change narcotic count, which was conducted by the oncoming CMA and a Licensed Practical Nurse (LPN). The overnight nurse, who was the only one with access to the medication cart during the time the pill went missing, stated she did not know where the medication went. The internal investigation revealed that the missing medication could not be found, and the facility's controlled drug count record showed missing signatures on several dates, indicating lapses in the documentation process. The facility's procedure for controlled substance count requires that two authorized persons count and validate the accuracy of narcotics supply at each shift change. However, the investigation found that a CMA did not follow this policy, as she counted by herself and found the medication missing. The Director of Nursing (DON) and the Administrator in Training (AIT) conducted a narcotic count and confirmed that all other controlled substances were accounted for. The report highlights that the facility's controlled substance policy was not adhered to, leading to the discrepancy in the narcotic count and the missing Methadone pill.
Failure to Document and Assess After Unwitnessed Fall
Penalty
Summary
The facility failed to assess and document necessary interventions following an unwitnessed fall involving a resident with moderately impaired cognition and multiple health conditions, including coronary artery disease, heart failure, hypertension, and renal disease. The incident report noted that the resident was found sitting on the floor in front of a recliner, claiming not to have fallen or sustained any injuries. Despite this, the facility's clinical records lacked documentation of follow-up fall assessments and neurological checks, which are critical in such situations. The Director of Nursing (DON) acknowledged that a late entry was made in the progress notes nearly three weeks after the incident, and confirmed that the fall was not added to the hot charting, leading to the omission of necessary assessments. The DON also reported that the facility does not have a specific neurological policy but follows standards of care, expecting staff to complete neurological assessments as per the assessment form. This oversight resulted in the failure to conduct timely and appropriate neurological assessments following the unwitnessed fall.
Failure to Secure Laundry Room and Supervise Residents
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision to prevent accidents. Specifically, the door to the laundry room was broken, allowing 11 mobile residents access to hazardous chemicals stored within. The Director of Nursing (DON) confirmed that the door had a key-coded pad but could be pushed open without entering a code. The door had been broken for a couple of months, and the facility was awaiting a new maintenance person to fix it. Staff interviews revealed that Resident #7, who has moderate cognitive impairment and is independent with ambulation and transfers, was found near the laundry room door looking for clothing. Staff also confirmed that hazardous chemicals were stored openly in the laundry room, posing a risk to residents who might access the area. Resident #7, who has diagnoses of hypertension and dissociative and conversion disorder, was observed seeking access to the laundry room. Staff H and Staff I confirmed that Resident #7 had been found near the laundry room door on separate occasions. The chemicals observed in the laundry room included Laundry Chlorine Destainer, Laundry Soft Sour, and Laundry Emulsion Detergent, all of which have hazardous warnings indicating they are harmful if swallowed, cause severe skin burns and eye damage, and are harmful upon contact with skin. The facility's failure to secure the laundry room and supervise residents adequately led to a significant safety hazard.
Failure to Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections, Appeals and Licensing (DIAL) for a resident who reported that a Certified Nursing Assistant (CNA) was being rough with them. The resident, who had no cognitive impairment and required assistance with various activities of daily living, reported that the CNA pushed hard on their right leg thigh area, causing them to yelp in pain. The CNA then left the room without completing the brief change, leaving the resident exposed. The facility conducted an internal investigation but did not report the incident to DIAL, as they concluded there was no harm and the resident did not feel the CNA's actions were intentional abuse. The facility's policy mandates that all allegations of abuse be reported to DIAL within two hours. Despite this, the facility did not report the incident, believing it was non-reportable due to the lack of harm and the resident's perception of the event. The Director of Nursing confirmed that no pending investigations had been sent to DIAL. The facility's failure to report the incident as required by their policy and state regulations constitutes a deficiency in their abuse reporting procedures.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure staff answered resident call lights and responded to resident needs in a timely manner, within fifteen minutes, for two residents. Resident #4, who has intact cognition and requires extensive assistance for transfers, bed mobility, dressing, and toileting, reported waiting longer than 15 minutes for her call light to be answered on at least two occasions. The facility's call light report confirmed that on one occasion, it took staff 26 minutes to respond to Resident #4's call light. Resident #6, who also has intact cognition and requires extensive assistance for bed mobility and transfers, reported similar delays. The call light report showed that it took staff 18 minutes to respond to Resident #6's call light on one occasion. Interviews with staff members revealed that there is a perceived lack of sufficient staffing, particularly on the 2pm-10pm shift, which contributes to the delays in answering call lights. Staff members expressed concerns about the adequacy of staffing levels to meet resident needs in a timely manner. The facility does not have a specific call light policy and relies on state guidelines for response times.
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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