Accura Healthcare Of Marshalltown
Inspection history, citations, penalties and survey trends for this long-term care facility in Marshalltown, Iowa.
- Location
- 2401 South Second Street, Marshalltown, Iowa 50158
- CMS Provider Number
- 165451
- Inspections on file
- 27
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Accura Healthcare Of Marshalltown during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and dementia was intentionally sprayed with cold water by a CNA at the end of a shower, despite objections from other staff and the resident's distress. Witnesses reported the CNA laughed during the incident and ignored requests to stop, violating the facility's abuse prevention policy and the resident's right to be free from abuse.
A resident with severe cognitive impairment was intentionally sprayed with cold water by a staff member during a shower, an act witnessed by two CNAs who did not immediately report the incident. The facility did not notify the State Agency of the abuse allegation within the required 2-hour window, as mandated by policy.
A resident with severe cognitive impairment was intentionally sprayed with cold water by a CNA during a shower, while other staff present protested the action. The incident was not immediately reported, and the CNA continued to work several shifts before the facility took action to investigate or separate the alleged abuser, contrary to facility policy.
A resident with intact cognition and multiple psychiatric diagnoses did not have their controlled medication, lorazepam, properly stored or documented after pharmacy delivery. Staff provided inconsistent accounts regarding the handoff and storage of the medication, and the required documentation and secure storage procedures were not followed, resulting in the medication being unaccounted for.
The facility did not correct repeated deficiencies in dignity, infection control, and food service processes, despite having a QAPI plan that required systematic identification and correction of such issues. The lack of follow-through on required audits by the previous DON and ongoing concerns in infection control and kitchen processes contributed to the continued deficiencies.
Surveyors identified deficiencies in food storage and handling, including undated and expired food items, improper use of gloves, and lack of beard nets for staff with facial hair. Staff failed to follow facility policies for labeling, discarding food, and maintaining sanitary conditions, as confirmed by the CDM.
Multiple residents with intact cognition reported being treated disrespectfully by the previous DON, who argued with them, used a demanding tone, made inappropriate comments about personal habits, and talked down to both residents and their families. Facility investigation and staff interviews confirmed a pattern of unprofessional conduct that did not meet expectations for respectful care.
Multiple residents reported significant delays in call light responses and unmet care needs due to insufficient staffing, with documented instances of waiting up to an hour or more for assistance. Staffing records showed that actual staff levels, particularly for CNAs and licensed nurses, were below the facility's own assessed requirements on several shifts, especially on weekends. The administrator acknowledged awareness of these staffing issues.
A resident with an indwelling urinary catheter and a history of neurogenic bladder and diabetes was repeatedly observed over several days with catheter tubing resting on or dragging across the floor while in a wheelchair. Staff interviews confirmed the expectation that tubing should be kept off the floor, but the facility's catheter care policy lacked specific guidance on this practice. The resident's care plan aimed to prevent UTIs, and the resident had recently been treated for a UTI.
Staff did not follow enhanced barrier precautions during wound care for a resident with a diabetic foot ulcer and risk for MDRO colonization. Despite clear care plan instructions and posted signage requiring gowns and gloves for high-contact care, an LPN and a CMA performed a dressing change without wearing gowns, contrary to facility policy.
A resident with moderately impaired cognition and multiple diagnoses did not receive appropriate eligibility screening, education, or documentation regarding follow-up pneumococcal vaccination. The facility only offered pneumonia vaccines at admission and did not ensure ongoing assessment or documentation of consent or refusal for recommended vaccines, contrary to CDC guidelines and facility policy.
A resident with Alzheimer's and a history of wandering left the facility unsupervised after staff failed to properly investigate a door alarm and confirm the resident's location. Staff did not follow policy requiring a thorough visual check of the exit area, resulting in the resident being found several blocks away before being safely returned.
A resident with multiple chronic conditions suffered a fall resulting in rib fractures and was ordered to receive PT and OT for pain management. The facility failed to initiate OT as ordered and delayed the start of PT for several weeks, despite staff being notified of the physician's orders. Leadership confirmed that therapy services were not provided in accordance with protocol.
The facility failed to maintain a safe and comfortable environment by not keeping resident equipment in good repair. Observations showed that several residents had wheelchairs with damaged armrests, inadequately repaired with tape. A resident's power wheelchair had electrical tape holding a cup holder in place. The Maintenance Supervisor acknowledged challenges in keeping up with repairs and lacked documentation for necessary repairs.
The facility failed to provide scheduled showers for four residents, leading to unmet personal hygiene needs. Residents reported receiving fewer showers than scheduled, with documentation showing inconsistencies and missed dates. The facility's policy required showers as requested or per schedule, but this was not adhered to, resulting in a deficiency in care.
The facility failed to provide adequate restorative nursing programs for residents with limited mobility, as documented in their care plans. A resident with heart failure and weakness did not receive prescribed ROM exercises, while another with hemiparesis lacked consistent exercise provision. Two other residents also did not receive their prescribed exercises. Staff confirmed the absence of a dedicated Restorative Assistant, contributing to the deficiency.
The facility failed to maintain the dignity and respect of two residents. One resident was left uncleaned by staff after a bowel movement, leading to feelings of degradation. Another resident experienced a verbal altercation with the DON, who had previously received counseling for communication issues. The incidents were not promptly addressed, highlighting deficiencies in resident care.
A resident with severe dementia and a stage 2 pressure ulcer did not receive Prostat as ordered in their wound treatment plan. The ADON documented the new treatment plan, but the MAR lacked the Prostat order, which was confirmed by an LPN. The DON expected staff to follow physician orders, but the facility could not provide a policy for this.
A facility failed to ensure safe operation of a mechanical lift by allowing underage CNAs to use it without adult supervision. A resident requiring substantial assistance was transferred by staff under 18, contrary to federal guidelines. The DON acknowledged the expectation for adult supervision, highlighting a lapse in compliance with safety regulations.
A facility failed to ensure CPR was performed by certified staff for a resident who had requested resuscitation. Despite the presence of a CPR-certified RN, non-certified CNAs performed CPR on the unresponsive resident until EMTs arrived. The facility's policy required CPR to be initiated by certified staff, which was not followed.
The facility's dietary staff failed to properly label and store food items, leading to outdated and unlabeled items in the kitchen, and did not ensure that dish machine temperatures were documented, compromising food safety and sanitation. The Dietary Manager confirmed these issues, which violated the facility's food storage policy.
The facility failed to screen, educate, and document COVID-19 vaccinations for three residents, despite CDC guidelines and facility policy. A resident with intact cognition and another with severely impaired cognition did not receive education or consent documentation for additional vaccinations after August 2022. Staff confirmed no vaccination clinics were held since then, and the facility's policy to offer vaccinations was not followed.
The facility failed to provide necessary safety smoking equipment for two residents, despite assessments indicating the need for supervision and smoking aprons. Observations showed that neither resident wore a smoking apron during supervised smoking times. Staff interviews revealed a lack of awareness about the residents' needs, highlighting a communication breakdown in the facility.
A facility failed to develop a comprehensive care plan for a resident with severely impaired cognition and a history of exit-seeking behavior. Despite multiple attempts by the resident to leave the facility, the care plan did not include the use of a wander guard, which was observed on the resident. Staff acknowledged the oversight, and the facility lacked a specific policy for wander guard use.
The facility failed to provide and document restorative care for three residents, leading to deficiencies in maintaining their ability to perform ADLs. One resident, with diagnoses including CHF and obesity, participated in restorative services only once in a 30-day period. Another resident, with impaired ROM due to a CVA, did not participate in any restorative activities despite recommendations. A third resident, with a history of stroke and hip fracture, also did not receive the recommended restorative care. Staff interviews highlighted inconsistencies in the implementation and documentation of restorative programs.
A resident with severe cognitive impairment and multiple health conditions experienced significant weight loss due to inconsistent supplement serving amounts. The facility's physician orders lacked specific instructions on supplement quantities, leading to varied administration by staff. Despite the resident's care plan and facility policy emphasizing the need for consistent nutrition interventions, the facility failed to ensure proper supplement administration, contributing to the resident's continued weight loss.
A CNA failed to follow infection control practices by not wearing a gown while performing urinary bag care for a resident with severe cognitive impairment and multiple infections. Additionally, the CNA did not properly rinse the graduate used for measuring urine, leaving it with residual urine, contrary to CDC guidelines. The facility's Enhanced Barrier Precaution policy required the use of gowns and gloves, which was not adhered to during the observation.
The facility did not post the daily nurse staffing information for its 53 residents, as observed on a specific day. The Administrator confirmed the absence of the posting and noted that the information was kept in a binder at the nurses' station, not accessible to residents and visitors. Additionally, the facility lacked a policy for daily nurse staffing postings, failing to adhere to the standard of care.
Resident Subjected to Physical Abuse During Shower
Penalty
Summary
A deficiency occurred when a Certified Nurse Aide (CNA) intentionally sprayed a resident with cold water at the end of a shower, despite the resident's cognitive impairment and care plan interventions. The resident, who had diagnoses of Alzheimer's disease, non-Alzheimer's dementia, and anxiety disorder, was assessed as having severely impaired cognition and required substantial assistance with showering. During the incident, the CNA told other staff to "watch this," turned the water to cold, and sprayed the resident for several seconds, causing the resident to become angry and strike the shower head against the wall. Two other CNAs were present during the incident. One CNA reported witnessing the event and described the resident as noncombative at the time, while the other CNA heard the resident yelling and saw the CNA continue to spray him with cold water despite being told to stop. Both witnesses stated that the CNA laughed during the incident, and the resident verbally expressed his discomfort and distress. The facility's policy clearly stated that all residents have the right to be free from abuse, including any act intended to cause pain, injury, or offensive physical contact. The incident was not reported immediately by the witnesses, as they did not initially recognize it as abuse. The Director of Nursing and Administrator both stated that staff are expected to treat residents with dignity and respect and to report suspected abuse immediately. The CNA involved denied intentionally spraying the resident, claiming it may have been accidental while turning off the water, but witness accounts contradicted this statement. The failure to protect the resident from physical abuse constituted a violation of the facility's abuse prevention policy.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner for a resident with severely impaired cognition and multiple diagnoses, including Alzheimer's disease and anxiety disorder. According to the facility's policy, allegations of abuse must be reported to the State Agency within 2 hours. On the date of the incident, a staff member intentionally sprayed the resident with cold water during a shower, an act witnessed by two other CNAs. The resident reacted by grabbing the shower head and banging it against the wall, and verbally expressed discomfort due to the cold water. Both witnesses acknowledged the incident but did not report it immediately, with one stating she was new and the other admitting she did not initially recognize the act as abuse. Interviews with staff revealed that both witnesses were present during the incident and discussed it afterward, but delayed reporting it to facility leadership. The Director of Nursing and Administrator confirmed that the expectation was for immediate reporting of suspected abuse, which did not occur in this case. The facility lacked documentation showing that the allegation was reported to the State Agency within the required 2-hour timeframe following the incident.
Failure to Timely Investigate and Separate Alleged Abuser Following Abuse Allegation
Penalty
Summary
The facility failed to investigate an allegation of abuse and did not separate the alleged perpetrator from residents in a timely manner. A resident with severely impaired cognition, requiring substantial assistance with showering and diagnosed with Alzheimer's, non-Alzheimer's dementia, and anxiety disorder, was involved in the incident. According to staff interviews and documentation, a CNA intentionally sprayed the resident with cold water during a shower, despite protests from other staff present. The resident reacted by yelling, screaming, and attempting to stop the action, while the CNA laughed and continued for 10-15 seconds. Two CNAs witnessed the event and told the perpetrator to stop, but the incident was not immediately reported. The facility's policy required immediate measures to prevent further potential abuse, such as suspending the employee, and prompt investigation and reporting to the State Agency. However, records show that the CNA continued to work several shifts after the incident before any action was taken. There was no documentation that the alleged abuser was separated from residents or that an investigation was initiated prior to several days after the event. The deficiency centers on the facility's failure to respond appropriately and promptly to an alleged violation of abuse policy.
Failure to Secure and Document Controlled Substance Storage
Penalty
Summary
The facility failed to store and handle controlled medications in accordance with professional standards for one resident. Specifically, a resident with diagnoses including anxiety disorder, schizophrenia, and hallucinations had an active order for lorazepam, a controlled substance. Documentation showed that a quantity of lorazepam was delivered by the pharmacy and signed for by an LPN. However, staff interviews revealed confusion and lack of clear documentation regarding the receipt and storage of the medication. The medication was not properly accounted for, with staff unable to locate it after delivery, and there was no documentation confirming the transfer of the medication between staff members. Staff involved in the medication handoff provided conflicting accounts of the events, with one nurse stating she gave medications to the ADON, who then returned them, and another nurse stating she did not receive any narcotics or related documentation. The DON confirmed uncertainty about the whereabouts of the missing medication and acknowledged that the process for checking in and storing narcotics was not followed as required. The facility's policy required that controlled substances be signed in and stored in a locked compartment, but this was not consistently done, resulting in the medication being unaccounted for.
Failure to Correct Repeated Deficiencies in QAPI Areas
Penalty
Summary
The facility failed to correct previously identified deficiencies in three areas: dignity, infection control, and food procurement/store/prepare/serve/sanitation. Despite having a QAPI plan in place that outlined systematic approaches for identifying and correcting quality deficiencies, the facility did not ensure that these processes were effectively implemented. The QAPI plan emphasized staff participation, accountability, and data-driven decision-making, but repeated deficiencies were still observed in the cited areas. The Administrator acknowledged that while a correction plan was developed for dignity concerns, the previous DON did not follow through with required audits as directed, and this lack of follow-through contributed to the ongoing issues. The repeated deficiencies in infection control and kitchen processes were also recognized during the survey, indicating that the facility's QAPI activities were not successful in addressing and resolving these concerns.
Deficient Food Storage, Labeling, and Sanitation Practices in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in food storage, labeling, and handling practices within the facility's kitchen. Several food and drink items, including tomato juice, soy milk, grape juice, white milk, chocolate milk, and orange juice, were found open and not dated. Additionally, containers of apricots, ham salad, and mixed berries were stored past their recommended discard dates. Staff interviews confirmed a lack of understanding regarding proper labeling and discard timelines, with one staff member incorrectly stating that food items remained good for three days after opening. The Certified Dietary Manager (CDM) verified that these items should have been discarded and that all opened food should be labeled and dated according to facility policy. Further observations revealed lapses in personal hygiene and food handling procedures. A male dietary aide with a beard was not wearing a beard net, contrary to facility policy, and reported he was unaware of the requirement. Staff preparing and serving food were seen wearing gloves for multiple tasks without changing them or performing hand hygiene between tasks, including handling utensils, food containers, and food items. On several occasions, staff donned new gloves without washing their hands, and used gloved fingers to handle food directly. The CDM confirmed that gloves should be used for a single task and changed to prevent cross-contamination, and that hand hygiene is required after glove removal.
Failure to Ensure Resident Dignity Due to Unprofessional Staff Conduct
Penalty
Summary
The facility failed to ensure residents' dignity and respect for five residents with intact cognition, as evidenced by multiple reports of unprofessional and disrespectful conduct by a staff member, specifically the previous Director of Nursing (DON), referred to as Staff A. Residents reported that Staff A argued with them, persisted in trying to convince them to perform activities such as showering against their wishes, and used a demanding and superior attitude, particularly during night shifts. Several residents described being talked down to, yelled at, or directed to go to their rooms in a manner they found disrespectful. One resident recounted Staff A making a blunt and upsetting comment about their eating habits in front of a family member, while another described Staff A as treating them like a child and being rude to their family member over the phone. Facility documentation and interviews with both residents and staff confirmed a pattern of inappropriate and unprofessional behavior by Staff A, including repeated complaints about her conduct. The facility's own investigation revealed that Staff A's actions did not align with the expectations of leadership and the facility's policy on employee standards and code of conduct, which requires staff to maintain a positive and respectful environment. The incidents involved residents who were cognitively intact, as indicated by their BIMS scores, and who were able to clearly articulate their experiences of being treated without dignity and respect.
Failure to Provide Adequate Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of delayed call light responses and unmet care needs. Several residents reported waiting from 30 minutes to over an hour for staff to respond to call lights, particularly during the day and night shifts. One resident noted that staff were too busy with other tasks, such as showers, resulting in delays in assistance with getting out of bed and eating meals. Another resident described being left unattended over the weekend due to short staffing, with staff indicating they would return but failing to do so. A grievance from a family member also documented long call light response times and uncompleted linen changes. Payroll Based Journal (PBJ) data and daily staff postings revealed that staffing levels, especially on weekends and certain shifts, were below the facility's own assessment of required staff-to-resident ratios. The facility assessment specified higher numbers of RNs, LPNs, CNAs, and medication aides per shift than were actually present according to the daily postings. The administrator acknowledged awareness of ongoing staffing concerns and indicated the facility assessment needed to be updated to reflect current needs.
Failure to Maintain Catheter Tubing Off the Floor for Resident with Indwelling Catheter
Penalty
Summary
Surveyors identified a deficiency in the care of a resident with an indwelling urinary catheter, who had diagnoses including neurogenic bladder and diabetes mellitus. Over a four-day review period, multiple observations were made of the resident sitting in a wheelchair with 6 to 7 inches of catheter tubing resting on or dragging across the floor in various locations throughout the facility, including the dining room, hallways, and at the nurses' station. These observations were consistent across several days and times, indicating a persistent issue. Staff interviews revealed that facility staff expected catheter tubing to be kept off the floor, with one CNA stating that the tubing should be placed in a dignity bag and clipped to the resident's leg to prevent it from touching the floor. However, the facility's catheter care policy did not provide specific direction regarding the placement of catheter tubing off the floor. The resident's care plan included a goal to prevent urinary tract infections, and the resident had a recent history of a UTI, as evidenced by a positive urine culture and antibiotic treatment.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to follow enhanced barrier precautions (EBP) during wound care for a resident with a diabetic foot ulcer and increased risk for colonization of multidrug resistant organisms (MDRO). The resident required substantial assistance with mobility and had multiple diagnoses, including diabetes, renal disease, and dementia. The care plan specifically directed staff to use EBP, and signage on the resident's door instructed staff to wear gloves and gowns during high-contact care activities such as wound care. During an observed dressing change, an LPN and a Certified Medication Aide assisted with the procedure but did not wear gowns as required by facility policy and posted instructions. The LPN acknowledged forgetting to don a gown despite having received education on the policy. The facility's policy, updated prior to the incident, clearly defined EBP and required the use of gowns and gloves during wound care for residents with wounds requiring dressings.
Failure to Screen, Offer, and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to conduct proper eligibility screening, offer, and provide education regarding the pneumococcal (pneumonia) immunization for a resident. Clinical record review showed that the resident, who had moderately impaired cognition and diagnoses including Alzheimer's disease, anxiety, and hypertension, had received the pneumococcal polysaccharide vaccine (PPV23) in the past. However, there was no documentation that the resident was offered or educated about the recommended follow-up pneumococcal vaccines (PCV20 or PCV21), nor was there documentation of consent or refusal for these vaccines. Staff interviews revealed that pneumonia vaccinations were only offered at admission, and subsequent eligibility for additional vaccinations was not routinely assessed or offered. The facility's policy required that all residents be given the opportunity and encouragement to receive pneumococcal vaccinations, but the process for ongoing review and offering of vaccines was not followed. The physician was expected to review vaccination history and order immunizations, but this did not consistently occur, resulting in a lack of compliance with CDC recommendations and facility policy.
Failure to Supervise Resident Resulting in Elopement
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's dementia and a history of wandering was not adequately supervised, resulting in the resident leaving the facility unsupervised. The resident, who had a BIMS score indicating intact cognition but was known to wander and required supervision for safety, was last seen walking toward the dining room. Staff assumed the resident had entered the dining room, but when a door alarm sounded, staff failed to immediately and thoroughly investigate the cause of the alarm or confirm the resident's whereabouts. Instead of conducting a prompt and comprehensive search, staff turned off the door alarm after a brief visual check and did not go outside to verify if anyone had exited the building. It was only after the resident could not be located inside that a head count and neighborhood search were initiated. The resident was eventually found several blocks away and returned to the facility without injury. Interviews revealed that staff did not follow the facility's policy, which required a visual check of the area around the exit, including outside the building, when a door alarm sounded. Documentation showed that the resident was considered at moderate risk for elopement due to his diagnosis and history, and the care plan directed staff to monitor and redirect him as needed. Despite these interventions, staff actions were insufficient to prevent the resident from leaving the facility, and the required protocols for responding to door alarms and missing residents were not followed as outlined in facility policy.
Failure to Initiate Ordered Therapy Services After Resident Fall
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for a resident following a fall that resulted in acute right posterior rib fractures. The resident, who had a history of hypertension, COPD, diabetes mellitus, and muscle weakness, experienced a fall in her room and subsequently complained of pain in her left shoulder, ankle, and ribs. Despite a physician's order for both physical therapy (PT) and occupational therapy (OT) evaluations and treatment due to increased pain, the clinical record showed that OT services were never initiated and PT services were not started until several weeks after the order was given. Documentation confirmed that the staff notified therapy of the new order, but there was no evidence that OT was ever provided, and PT was delayed significantly. Interviews with facility leadership verified that the staff did not follow the physician's orders according to facility protocol, and there was no policy in place regarding the timely processing of such orders. The failure to initiate therapy services as ordered constituted a deficiency in providing required specialized rehabilitative services.
Failure to Maintain Resident Equipment in Good Repair
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents by not keeping their equipment in good repair. Observations revealed that four residents had wheelchairs with damaged armrests, including torn vinyl and exposed foam, which were inadequately repaired with tape. Specifically, Resident #13's wheelchair had a torn right armrest, Resident #15's wheelchair had a right armrest wrapped with clear plastic tape, and Resident #5's wheelchair had both armrests with torn vinyl and exposed foam. Additionally, Resident #2's power wheelchair had black electrical tape on the left armrest to hold a cup holder in place. The Maintenance Supervisor admitted difficulty in keeping up with necessary repairs and lacked documentation for the repairs needed on resident wheelchairs.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide showers per the residents' requests for four residents, leading to a deficiency in care. Resident #6, with intact cognition and requiring substantial assistance due to left-sided hemiparesis, reported receiving only one shower a week and expressed a preference for a bed bath as a second option. Documentation for November 2024 through January 2025 showed inconsistencies and lack of records indicating that Resident #6 received the scheduled showers, with several instances of refusal noted without alternative care provided. Resident #1, also with intact cognition and requiring partial to maximum assistance, reported receiving fewer showers than scheduled, sometimes not even one per week. Documentation from November 2024 to January 2025 revealed multiple missed scheduled showers, with no records indicating that Resident #1 received the necessary personal hygiene care. Similarly, Resident #14, who required substantial assistance, confirmed not receiving the scheduled twice-weekly showers, with documentation showing several missed dates in November and December 2024, and no records for January 2025. Resident #7, who was independent in showering, reported receiving only one shower a week at times, despite a schedule of two showers per week. Documentation indicated refusals on several dates, with limited records of showers being provided. Interviews with staff revealed issues with equipment suitability for Resident #8, who was not directly part of the deficiency but highlighted potential systemic issues. The facility's policy required showers as requested or per schedule, but the documentation and resident reports indicated a failure to adhere to this policy, resulting in unmet personal hygiene needs.
Failure to Provide Adequate Restorative Nursing Programs
Penalty
Summary
The facility failed to provide adequate restorative nursing programs to maintain or improve the mobility of four residents with limited range of motion and mobility issues. Resident #13, with intact cognition and multiple diagnoses including heart failure and weakness, did not receive the prescribed active range of motion (ROM) exercises with weights and a green band for the upper body, as documented in their care plan. Despite having a care plan that included these interventions, there was no documentation of restorative therapy being provided for the entire month, and the resident confirmed the lack of exercises during an interview. Resident #6, also with intact cognition and functional limitations in range of motion due to left-sided hemiparesis, was supposed to receive active ROM exercises using a MOTOmed and a green TheraBand. However, the documentation did not reflect that these exercises were consistently provided, with only one instance of exercise recorded. The resident confirmed the absence of restorative therapy, expressing a desire to participate in the recommended exercises. Similarly, Resident #5 and Resident #1, both with intact cognition and various medical conditions, did not receive the prescribed ROM exercises as outlined in their care plans. Resident #5's documentation lacked evidence of consistent exercise provision, while Resident #1's records showed sporadic exercise offerings. Interviews with staff confirmed that the facility did not have a dedicated Restorative Assistant to ensure the completion of these programs, contributing to the deficiency in providing necessary mobility services to the residents.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, impacting their quality of life. One resident, with intact cognition and a history of trauma, was left uncleaned by staff after a bowel movement, which made her feel degraded. This incident was reported during a resident council meeting, but the facility's administration was unaware of it until the meeting minutes were reviewed. The Director of Nursing was not informed of the incident, and no immediate investigation was conducted. Another resident, also with intact cognition and diagnosed with multiple sclerosis and depression, experienced an altercation with the Director of Nursing shortly after admission. The resident and the DON had a verbal argument, during which the DON raised her voice. The incident was self-reported, and the resident expressed that they had moved past the issue. The DON had previously received educational counseling to improve interactions with residents and staff. The facility's failure to address these incidents promptly and effectively highlights a deficiency in maintaining residents' dignity and respect. The lack of immediate action and communication among staff and administration contributed to the residents' negative experiences, as documented in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with severe dementia, cerebral atherosclerosis, and incontinence, and was at risk for developing pressure ulcers. The resident had a stage 2 pressure ulcer on the sacrum upon admission. A Wound Treatment Plan dated December 13, 2024, included orders to discontinue the current treatment and start a new regimen, which involved cleansing the wound, applying a collagen pad, and covering it with a silicone super absorbent dressing. Additionally, the plan included administering Prostat, a nutritional supplement, to promote wound healing. However, the Medication Administration Record (MAR) for December 2024 and January 2025, as well as the Clinical Physician Orders printed on January 9, 2025, lacked the order for Prostat. The Assistant Director of Nurses (ADON) documented the new wound treatment plan in the Nurses Notes, MAR, and Treatment Administration Record (TAR) on December 16, 2024, and notified the resident's family. Despite this, the order for Prostat was not included in the MAR, which was confirmed by a Licensed Practical Nurse (LPN) on January 13, 2025. The ADON acknowledged not seeing the order for Prostat on the Wound Treatment Plan received on December 13, 2024. The Director of Nursing (DON) confirmed that staff are expected to follow physician orders. The facility was unable to provide a policy for following physician orders, indicating a lapse in ensuring adherence to prescribed treatments.
Underage Staff Operate Mechanical Lift Without Supervision
Penalty
Summary
The facility failed to ensure the safe operation of a full-body mechanical lift by allowing workers under the age of 18 to operate the lift without adult supervision. This deficiency was identified through resident and staff interviews, revealing that the facility did not adhere to the guidelines set forth by the Fair Labor Standards Act (FLSA) regarding the operation of power-driven hoisting apparatus by minors. Specifically, the facility allowed Certified Nursing Assistants (CNAs) and nursing assistants under the age of 18 to use the lift without the presence of an adult over the age of 18, which is a violation of the child labor provisions. Resident #6, who had a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition, required substantial to total assistance with activities of daily living due to conditions such as stroke, hemiplegia, and renal insufficiency. The care plan for Resident #6 specified that assistance from two staff members was needed for all transfers using the lift. However, on a specific date, Resident #6 was transferred using the lift by Staff A, Staff B, and Staff C, all of whom were under the age of 18, without adult supervision. Additionally, Staff C had not received training on how to use the facility's lift. The Director of Nursing (DON) acknowledged that staff under the age of 18 were expected to have someone over the age of 18 present when operating a lift. The facility's failure to comply with these expectations and federal regulations resulted in the improper use of the mechanical lift, as the CNAs involved did not have the necessary supervision or training to safely operate the equipment. This oversight posed a risk to both the residents and the underage staff involved in the transfer process.
Failure to Ensure CPR Certified Staff Performed Resuscitation
Penalty
Summary
The facility failed to ensure that staff certified in cardiopulmonary resuscitation (CPR) performed the procedure for a resident who had requested CPR in their care plan and had signed an Iowa Physician Orders for Scope of Treatment (IPOST) indicating their desire for resuscitation. The incident involved a resident with intact cognition and medical conditions including coronary artery disease, hypertension, and atrial fibrillation. On the day of the incident, the resident was found unresponsive, and although a registered nurse (RN) with CPR certification was present, the CPR was performed by certified nurse aides (CNAs) who were not certified in CPR. The RN, identified as Staff A, initially assessed the resident and left to call 911, during which time the resident stopped breathing. Despite being CPR certified, Staff A directed the CNAs to perform CPR, and they took turns doing so until emergency medical technicians arrived. Interviews revealed that the CNAs involved were not CPR certified, and another RN, Staff D, who was CPR certified, did not assist with the CPR efforts. The facility's policy required that CPR be initiated by any staff member currently certified to perform it, which was not adhered to in this case.
Deficiencies in Food Storage and Sanitization Practices
Penalty
Summary
The dietary staff at the facility failed to properly label and store food items, which compromised food quality and increased the risk of contamination and foodborne illness. During an initial tour of the main kitchen, several issues were identified, including outdated food items in the cooler, such as a squirt bottle of ranch dated 7/8/24, a squirt bottle of French dressing dated 6/30/24, and a bag of bacon bits dated 7/13/24. Additionally, four out of five plastic containers of cereal were either unlabeled or had outdated labels, and plastic containers under the prep table were either incompletely labeled or not labeled at all. There were also undated and unlabeled bags of cereal in dry storage, unsecured plastic bags of pasta, and a box labeled cocoa powder with another bag placed on top of a partially opened bag of cocoa powder. The facility also failed to ensure that resident dishes and kitchen equipment reached the appropriate sanitizing temperature when using the dish machine, as evidenced by missing entries in the dish machine temperature log for several days in July 2024. The Dietary Manager confirmed the lack of documented temperatures and acknowledged the presence of outdated and improperly labeled food items. The facility's policy on food storage requires that food be dated when placed on shelves, stored in containers with tight-fitting covers or sealable bags, and labeled and dated accurately. Leftover food should be used or discarded within seven days, but these procedures were not consistently followed, leading to the identified deficiencies.
Failure to Provide COVID-19 Vaccination and Documentation
Penalty
Summary
The facility failed to comply with CDC guidelines and its own policy regarding COVID-19 vaccinations for residents. Specifically, the facility did not screen for eligibility, offer, provide education, or document vaccine consent or refusal for three residents. Resident #23, with intact cognition, had received a COVID-19 vaccination in August 2022, but there was no documentation of education or consent for an additional vaccination. Similarly, Resident #43, with severely impaired cognition, also lacked documentation of education or consent for an additional vaccination after receiving one in August 2022. Resident #22, with intact cognition, had a similar deficiency in documentation for an additional vaccination. The facility's failure to offer updated COVID-19 vaccinations was further highlighted by staff interviews. The Administrator and ADON confirmed that no vaccination clinics had been held since August 2022, and the QA Nurse reported the last attempt to set up a clinic was in March 2023. The facility's policy, updated in May 2024, stated that residents should be provided the opportunity to receive COVID-19 vaccinations, and if a resident wished to be up to date, the facility would contact the primary physician for an order. However, this policy was not followed for the residents in question.
Failure to Provide Safety Smoking Equipment for Residents
Penalty
Summary
The facility failed to accurately assess the need for safety smoking equipment for two residents, leading to a deficiency in ensuring resident safety during smoking activities. Resident #56, who had severely impaired cognition and used a wheelchair, was assessed as having no cognitive losses and was noted to require supervision and a smoking apron. However, observations on two separate occasions revealed that Resident #56 was not wearing a smoking apron during supervised smoking times. This discrepancy between the assessment and actual practice indicates a failure in implementing the necessary safety measures as outlined in the resident's care plan. Similarly, Resident #22, who had intact cognition and used a manual wheelchair, was assessed to need supervision and a smoking apron. Despite this, observations showed that Resident #22 was not wearing a smoking apron during supervised smoking times. Interviews with staff, including a CNA and the ADON, revealed a lack of awareness regarding the need for smoking safety equipment for these residents. The staff expressed surprise and concern upon learning about the inaccurate assessments, indicating a breakdown in communication and documentation processes within the facility.
Failure to Implement Comprehensive Care Plan for Resident with Exit-Seeking Behavior
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of exit-seeking behavior. The resident, who had severely impaired cognition and utilized a wheelchair, had attempted to leave the facility on multiple occasions. Despite these incidents, the care plan did not include information regarding the resident's wandering behavior or the need for a wander guard. The clinical record review also did not show an active order for the use of a wander guard or instructions for staff to check its placement. Observations and staff interviews confirmed that the resident was wearing a wander guard, yet the care plan did not reflect this intervention. A registered nurse acknowledged the oversight and noted that the care plan should address the resident's fluctuating exit-seeking behaviors and the current use of a wander guard. Additionally, the facility lacked a policy or procedure specifically related to wander guard use or care plan development, as confirmed by the facility administrator.
Deficiency in Restorative Care Documentation and Implementation
Penalty
Summary
The facility failed to provide and document restorative care for three residents, leading to deficiencies in maintaining their ability to perform activities of daily living (ADLs). Resident #7, with intact cognition and diagnoses including congestive heart failure and obesity, was recommended for a restorative nursing program (RNP) after being discharged from occupational therapy. Despite the recommendations, documentation showed that Resident #7 only participated in restorative services once in a 30-day period, and staff interviews confirmed the lack of consistent participation and documentation. Resident #24, who had impaired range of motion due to a cerebrovascular accident, was also not provided with adequate restorative care. Although physical therapy recommended an RNP to prevent ADL decline, documentation revealed that Resident #24 did not participate in any restorative activities during the look-back periods. Interviews with staff indicated a lack of awareness and documentation of the resident's participation in restorative programs, despite the resident's need for extensive assistance with ADLs. Similarly, Resident #43, who required assistance due to a history of stroke and hip fracture, did not receive the recommended restorative care. The care plan included group exercises and the use of an exercise bike, but documentation showed a lack of participation in these activities. Staff interviews highlighted inconsistencies in the implementation and documentation of the resident's restorative program, contributing to the deficiency in maintaining the resident's functional abilities.
Inconsistent Supplement Administration Leads to Resident Weight Loss
Penalty
Summary
The facility failed to implement consistent supplement serving amounts for a resident with severe cognitive impairment and multiple health conditions, including anemia, hypertension, heart failure, renal disease, diabetes, cerebrovascular accident, non-Alzheimer's disease, malnutrition, dysphagia, and anoxic brain damage. The resident required supervision and assistance with eating and had a history of weight loss. Despite the resident's care plan directing staff to serve supplements as ordered, the physician's orders lacked specific instructions on the amount of supplement to administer. The resident's weight decreased significantly over several months, with a notable weight loss of 10.3% in 180 days and 12.6% in 180 days. The facility's records showed that the resident's supplement intake was documented, but the amount consumed was not specified. Staff interviews revealed inconsistencies in the amount of supplement given, with some staff administering varying amounts based on the resident's mood and willingness to consume the supplement. The Director of Nursing acknowledged the lack of specific directions in the physician's orders and the inconsistency in serving amounts. The facility's policy on nutrition interventions for unintended weight loss emphasized the importance of determining appropriate calorie, protein, and nutrient needs for residents. However, the facility did not adhere to these guidelines, as evidenced by the lack of specific supplement serving instructions and the resident's continued weight loss. The Director of Nursing and other staff members recognized the issue but did not take corrective action to ensure consistent supplement administration.
Infection Control Deficiency: Improper PPE Use and Equipment Cleaning
Penalty
Summary
The facility staff failed to adhere to infection control practices, specifically in the use of personal protective equipment (PPE) and proper cleaning of resident equipment. During an observation, a certified nursing assistant (CNA), identified as Staff G, was seen performing urinary bag care for a resident with severe cognitive impairment and multiple medical conditions, including septicemia and a urinary tract infection. The resident required total assistance for personal hygiene and had a urinary catheter. Despite the facility's Enhanced Barrier Precaution (EBP) policy requiring the use of gowns and gloves for residents with indwelling medical devices, Staff G only wore gloves and did not don a gown while emptying the urinary bag. Additionally, after emptying the urinary bag, Staff G did not rinse the graduate used for measuring urine, leaving it with a small amount of urine present. This action was contrary to the CDC guidelines, which recommend using a separate, clean collection container for each patient. The Assistant Director of Nursing (ADON) confirmed that Staff G self-reported not wearing a gown and acknowledged the CNA's preference for using a cup to rinse the graduate, although it was unclear if this was done. The failure to follow these infection control practices was observed despite the presence of EBP signage on the resident's door, which outlined the required PPE.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information, as required, for a reported census of 53 residents. On July 23, 2024, at 11:50 AM, it was observed that the facility did not have the daily nurse staffing information posted. At 12:00 PM, the Administrator acknowledged and confirmed the absence of the posting and stated that the information was not readily accessible to residents and visitors. Instead, the daily nurse schedules were kept in a binder at the nurses' station. The Administrator also reported that the facility did not have a policy regarding the daily nurse staffing postings and admitted that the facility did not follow the standard of care in this instance.
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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