Accura Healthcare Of Onawa
Inspection history, citations, penalties and survey trends for this long-term care facility in Onawa, Iowa.
- Location
- 222 North 15th Street, Onawa, Iowa 51040
- CMS Provider Number
- 165256
- Inspections on file
- 21
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Accura Healthcare Of Onawa during CMS and state inspections, most recent first.
The facility did not have an RN on duty for 8 consecutive hours on two days, as confirmed by the DON and a review of the nursing schedule. The staffing plan was based on census, acuity, and hiring availability, but there was no formal policy on RN coverage.
The facility did not post the correct lunch menu and failed to ensure residents were offered meal alternatives. Staff served a different meal than what was posted, did not consistently ask residents about their meal preferences, and several residents reported not being informed of or offered alternatives, including those with dietary restrictions or food intolerances. The Dietary Manager was unaware of a policy regarding food choices, and the process for offering alternatives was not reliably completed.
Surveyors found that staff did not consistently discard expired food items, including shredded carrots and graham cracker crumbs, until prompted during inspection. The Dietary Manager was unaware of a policy for routine checks of outdated food, despite the facility having a policy for discarding expired items brought in by families or visitors.
A resident with moderate cognitive impairment reported missing personal clothing items, which were not replaced despite notifying staff. Staff interviews revealed inconsistent use and awareness of inventory sheets, and the resident's inventory record could not be found, resulting in a failure to safeguard the resident's belongings.
A resident with multiple medical conditions and significant pain management needs received both scheduled and PRN oxycodone, but the facility failed to accurately document and monitor the administration of this controlled substance. Discrepancies were found between the number of tablets delivered, administered, and recorded, and required signatures were missing from drug count records. Staff also used a single sheet for multiple orders, contrary to facility policy.
A resident with multiple health conditions, including ESRD and diabetes, received Midodrine despite physician orders to withhold it when systolic BP exceeded 130. The medication was administered multiple times in June when BP readings were above this threshold, indicating non-compliance with the prescribed parameters.
A facility failed to conduct timely assessments for a readmitted resident with diabetes and end-stage renal disease. Upon readmission, staff did not document current vital signs or obtain a blood glucose level, despite care plan requirements and hospital discharge instructions. The DON noted that vital signs were recorded on paper but not entered electronically, and there was no policy on admission assessments.
The facility failed to conduct pre-dialysis assessments for two residents requiring hemodialysis. One resident, with moderate cognitive deficits and multiple diagnoses, was sent to the ED with a high pulse and low blood pressure without prior vital sign documentation. Another resident, with severe cognitive deficits, also lacked pre-dialysis assessments. The DON stated that dialysis staff completed these assessments, contrary to facility policy.
The facility's kitchen was found in unsanitary conditions during an inspection, with grease, food splatter, and debris on the stove top, shelving, carts, and floor. The Dietary Manager acknowledged the issue, attributing it to an employee's weekend work, despite routine cleaning logs being completed.
A facility failed to send a bed hold notice to a resident or their responsible person after a verbal consent was given during a transfer to the emergency room. The resident, with heart failure, hyperlipidemia, and asthma, was transferred and returned within a few days. The clinical record lacked documentation of the required notice, contrary to the facility's policy.
A facility failed to resubmit the PASRR for a resident with new mental health diagnoses and ongoing services. The resident had diagnoses of depression, anxiety disorder, and PTSD, but the PASRR did not reflect these or the mental health services received. The BOM acknowledged the oversight, and the facility's policy lacked guidance on PASRR resubmission requirements.
A facility failed to complete necessary skilled assessments for a resident with paraplegia, COPD, and neurogenic bladder, who was readmitted after hospitalization for Acute Kidney Injury. Despite the requirement for twice-daily assessments, several were missed, and the facility's policy lacked clear instructions on assessment frequency. The DON confirmed the oversight, with no additional documentation found.
A facility failed to follow mechanical lift requirements, leading to a deficiency in accident prevention. A resident with paraplegia and other conditions was transferred using a mechanical lift by two CNAs, who did not lock the wheelchair brakes as required by the lift's guide and facility policy. The DON confirmed the brakes should have been applied.
The facility did not follow the prescribed menu for mechanical soft diets, serving peas instead of buttered waxed beans to four residents. The Dietary Manager acknowledged the error, and the Dietician confirmed the importance of adhering to the menu to accommodate residents with chewing difficulties. The Director of Nursing expected staff to follow the planned therapeutic menus.
A facility failed to implement Enhanced Barrier Precautions (EBP) during wound care for a resident. An RN did not wear a gown as required by EBP guidelines while changing a dressing on a resident's heel. The RN admitted to not being trained on EBP, and the DON confirmed that gowns should be worn during such procedures.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for 8 consecutive hours each day, as required. A review of the April 2025 nursing schedule revealed that there was no RN coverage on two specific days, the 13th and the 17th. The Director of Nursing (DON) confirmed the absence of RN coverage on these dates. Additionally, a nurse consultant was unsure if there was a formal policy regarding RN coverage but stated that the facility follows the standard of care to provide 8 consecutive hours of RN coverage daily. The facility assessment indicated that staffing plans are based on census, acuity, and hiring availability, with a reported census of 32 residents at the time.
Failure to Post Correct Menu and Offer Meal Alternatives
Penalty
Summary
The facility failed to post the correct lunch menu and did not ensure that residents were offered meal options as required. On the day of observation, the posted menu listed spaghetti with meat sauce, seasonal vegetable, garlic toast, and pumpkin dessert for lunch, but the meal actually served was goulash, garlic toast, mixed vegetables, and poppy seed cake. Staff reported that menu changes were due to transitioning to a new management company and using up existing food supplies. The dietary staff did not complete the task of asking residents about meal alternatives that morning, and residents were not informed of the menu changes. Multiple residents reported that they were not asked about their meal preferences or offered alternatives, despite facility documents stating that dietary staff should be informed of alternatives by a specific time. One resident with intact cognitive ability noted that staff did not always come around to ask about meal choices. Another resident with a moderate cognitive deficit could not tolerate peas in the mixed vegetables and was not offered a substitute. A third resident on a low salt, diabetic diet stated she would have preferred a smaller portion if asked. The Dietary Manager was unaware of any facility policy on food choices, and the process for offering alternatives was inconsistently followed.
Failure to Discard Outdated Food Items in a Timely Manner
Penalty
Summary
Surveyors observed that the facility failed to discard outdated food items in a timely manner. During an inspection of the kitchen and storage areas, a bag of shredded carrots was found in the walk-in refrigerator with an expiration date that had already passed, and staff disposed of it only after it was pointed out. In the dry storage area, two bags of graham cracker crumbs were found with an open date several months prior, and the Dietary Manager was unable to confirm their expiration date but agreed they should be discarded. The Dietary Manager stated that checks for outdated food were typically done on delivery days, and there was no awareness of a specific policy for regularly checking for outdated food, despite the facility having a policy for discarding expired food brought in by families or visitors. The facility reported a census of 32 residents at the time of the survey.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property from loss or theft, as evidenced by the missing blouse and two pairs of jeans reported by a resident with moderate cognitive impairment. The resident stated she informed staff about the missing items, but they were never replaced. Staff interviews revealed a lack of awareness and inconsistent completion of inventory sheets, with one staff member admitting she did not know she was responsible for maintaining these records until a recent change in laundry service. The resident's inventory sheet could not be located. The facility's policy requires appropriate action when residents' rights are violated, but the deficiency occurred due to the failure to properly document and safeguard the resident's belongings.
Failure to Accurately Document and Monitor Controlled Substance Administration
Penalty
Summary
The facility failed to accurately document and monitor the use of controlled substances for a resident who was prescribed both scheduled and PRN oxycodone for pain management. The Controlled Drug Count Record (CDCR) did not match the Medication Administration Record (MAR), with discrepancies in the number of tablets administered and recorded. Specifically, the pharmacy delivered a total of 106 oxycodone tablets, but the MAR showed 85 administrations while the CDAR indicated 105 tablets had been administered. Additionally, the CDCR was missing required signatures on several dates, and staff reported that both scheduled and PRN doses were being tracked on the same sheet, contrary to facility policy, which required separate sheets for each prescription. The resident involved had multiple diagnoses, including anemia, renal insufficiency, pneumonia, cellulitis, and pressure ulcers, and was dependent on staff for toileting and transfers. The care plan indicated ongoing pain related to wounds, and the resident reported experiencing pain and delays in receiving medication. Staff interviews confirmed inconsistencies in the documentation and counting process for controlled substances, and policy review revealed that the facility was not following its own procedures for controlled substance documentation.
Failure to Follow Medication Orders for Blood Pressure Management
Penalty
Summary
The facility failed to adhere to medication orders for a resident with a prescription for Midodrine, intended to treat low blood pressure. The physician's order specified that the medication should be withheld if the resident's systolic blood pressure exceeded 130. However, during June 2024, the medication was administered multiple times when the resident's systolic blood pressure was above the specified threshold. Specific instances included blood pressure readings of 135/95, 148/75, 138/74, and others, indicating a clear deviation from the prescribed parameters. The resident involved had a moderate cognitive deficit and was dependent on staff for daily activities, including transfers and dressing. The resident's medical history included conditions such as anemia, hypertension, gastroesophageal reflux disease, end-stage renal disease, and diabetes mellitus. The care plan required staff to monitor vital signs and communicate with the dialysis unit, given the resident's need for hemodialysis. Despite these directives, the facility's staff failed to follow the physician's order regarding the administration of Midodrine, as evidenced by the medication administration records.
Failure to Conduct Timely Assessments for Readmitted Resident
Penalty
Summary
The facility failed to provide complete and timely assessments and interventions for a resident who was readmitted after a long hospitalization. Upon readmission, the staff did not document current vital signs and failed to obtain a blood glucose level, which was necessary due to the resident's diabetes mellitus. The resident's care plan required monitoring for signs of renal insufficiency and blood sugar levels, but these were not adequately followed. The Director of Nursing (DON) acknowledged that the admitting nurse documented vital signs on paper but did not enter them into the electronic chart, and there was no documentation of a blood glucose check upon admission. The resident had a history of anemia, hypertension, gastroesophageal reflux disease, end-stage renal disease, and diabetes mellitus, requiring hemodialysis and insulin management. The hospital discharge instructions specified that blood glucose should be checked before meals and at bedtime, with specific thresholds for notifying the physician. However, the facility did not have a policy on admission assessments, and the insulin was not delivered from the pharmacy on the day of readmission. The DON stated that the resident was not showing symptoms of hypo or hyperglycemia, and there was no order for blood glucose checks, which contributed to the oversight.
Failure to Conduct Pre-Dialysis Assessments
Penalty
Summary
The facility failed to conduct pre-dialysis assessments for two residents who required hemodialysis services. Resident #1, with moderate cognitive deficits and multiple diagnoses including end-stage renal disease, was dependent on staff for daily activities and required regular hemodialysis. The care plan directed staff to monitor vital signs and communicate with the dialysis unit. However, records showed that on several occasions in June, staff did not document pre-dialysis assessments, including vital signs or weights. On one occasion, the resident was sent to the emergency department with a high pulse and low blood pressure, and there was no documentation of vital signs before the resident was sent to dialysis. Similarly, Resident #3, with severe cognitive deficits and dependent on staff for daily activities, required hemodialysis due to renal failure. The care plan also required staff to monitor vital signs and report significant changes. However, in July, staff failed to document pre-dialysis assessments on multiple occasions. The Director of Nursing stated that the facility staff did not perform pre-dialysis assessments because the dialysis department completed them, leaving the form blank for dialysis nurses. This practice was contrary to the facility's policy, which required nurses to record vital signs and other relevant information before and after dialysis appointments.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen where food was prepared and stored, as observed during a walkthrough. The inspection revealed a thick layer of grease with food splatter and debris on the stove top, food debris and dried liquid on open shelving, scattered food debris on two carts, and an accumulation of food debris and dried liquid on the floor. The Dietary Manager acknowledged these unsanitary conditions and noted that routine cleaning logs were completed, but attributed the issue to an employee who worked over the weekend. The facility's Cleaning and Sanitizing policy, last revised in June 2015, emphasizes maintaining a clean and sanitary environment, but these standards were not met during the inspection.
Failure to Provide Bed Hold Notice After Resident Transfer
Penalty
Summary
The facility failed to ensure that a bed hold notice was sent to a resident or the resident's responsible person after a verbal consent was given when the resident was transferred out of the facility. This deficiency was identified for one of the three residents reviewed, specifically Resident #19, who had diagnoses of heart failure, hyperlipidemia, and asthma, with a BIMS score of 13 indicating no cognitive impairment. The resident was transferred to the emergency room on 8/26/23 and returned to the facility on 8/29/23. The clinical record review revealed that the bed hold dated 8/26/23 lacked documentation of a bed hold notice being sent, despite the facility's policy requiring written notification within a specified timeframe in cases of emergency transfer.
Failure to Resubmit PASRR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to resubmit the Preadmission Screening and Resident Review (PASRR) for a resident who had new mental health diagnoses and had begun receiving mental health services. The resident, identified as Resident #2, had documented diagnoses of depression, anxiety disorder, and post-traumatic stress disorder (PTSD) on their Minimum Data Set (MDS) assessment. Despite these diagnoses and the initiation of mental health services, the PASRR Level I Determination dated 4/9/24 did not reflect the active diagnosis of major depressive disorder and PTSD, nor did it document the ongoing behavioral health services the resident was receiving. The deficiency was identified through a review of clinical records, staff interviews, and policy review. The Business Office Manager (BOM) acknowledged that the PASRR should have been resubmitted, indicating a lapse in the facility's process for updating PASRRs when there are significant changes in a resident's mental health status. Additionally, the facility's Pre-Admission Screening policy failed to instruct staff on the requirements for resubmitting a PASRR, contributing to the oversight. Interviews with facility staff revealed that the responsibility for PASRR resubmissions was in transition, with plans to assign this task to a new social worker once training was completed.
Failure to Complete Skilled Assessments for Resident
Penalty
Summary
The facility failed to complete necessary skilled assessments for a resident, leading to a deficiency in maintaining the resident's highest practical physical well-being. The resident, who had diagnoses of paraplegia, Chronic Obstructive Pulmonary Disease (COPD), and neurogenic bladder, was hospitalized for an Acute Kidney Injury and returned to the facility. Despite the requirement for skilled assessments to be conducted twice daily from the resident's readmission, the facility did not complete these assessments on several specified dates. The Director of Nursing (DON) confirmed that the skilled assessments were not completed as required, and no additional documentation was found in the Progress Notes. The facility's policy from August 2015 instructed staff to enter a narrative note once a day but did not specify the frequency of skilled assessments, contributing to the oversight. This lack of adherence to assessment protocols resulted in a failure to provide appropriate treatment and care according to the resident's needs and goals.
Failure to Lock Wheelchair Brakes During Mechanical Lift Transfer
Penalty
Summary
The facility failed to adhere to mechanical lift requirements, resulting in a deficiency related to accident hazards and inadequate supervision. Resident #2, who has diagnoses of paraplegia, chronic obstructive pulmonary disease (COPD), and neurogenic bladder, was observed being transferred from bed to wheelchair using a mechanical lift by two Certified Nurse's Aides (CNAs). The resident, who is totally dependent on assistance for transfers, was not properly secured as the CNAs did not lock the wheelchair brakes before lowering the resident into the wheelchair. This action was contrary to the instructions in the mechanical lift's Owner's Guide and the facility's Lift Devices policy, which both mandate locking the wheelchair brakes during such transfers. The Director of Nursing (DON) confirmed that the wheelchair brakes should have been applied in accordance with the lift operator's guide.
Failure to Follow Mechanical Soft Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menu for mechanical soft diets for four residents during meal service. On the specified date, the Dietary Manager served peas instead of the buttered waxed beans that were listed on the therapeutic mechanical lunch menu. This deviation from the menu affected four residents who were supposed to receive mechanical soft diets. The Dietary Manager acknowledged the error upon review of the menu and expressed uncertainty about the reason for the specific menu item, suggesting a lack of understanding of the dietary requirements. The Dietician confirmed that the menu should have been followed and explained that the mechanical soft diet is intended for individuals with chewing difficulties, which may include those with dental issues or other conditions affecting chewing. The facility's Menu Planning Guide specifies that certain foods, including peas, should be omitted from mechanical soft diets due to potential chewing or swallowing difficulties. The Director of Nursing also acknowledged awareness of the potential issues certain foods could cause and expressed an expectation for staff to adhere to the planned therapeutic menus.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to adhere to universal infection control measures and Enhanced Barrier Precautions (EBP) during wound care for one resident. During an observation, a Registered Nurse (RN) performed hand hygiene and donned gloves before removing the old dressing from a resident's left heel. After removing the dressing, the RN doffed the gloves, performed hand hygiene again, and donned new gloves to complete the dressing change as ordered by the physician. However, the RN did not wear a gown during the procedure, which is required by EBP guidelines. In an interview, the RN admitted to not being trained on EBP and acknowledged that a gown should have been worn during the wound care. The Director of Nursing (DON) confirmed that the expectation was for gowns to be worn during such procedures. The facility's infection control policy and CDC guidelines both emphasize the importance of wearing gowns to protect skin and prevent clothing contamination during procedures likely to generate splashes or sprays of bodily fluids, especially when dealing with chronic wounds.
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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