Accura Healthcare Of Pleasantville, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasantville, Iowa.
- Location
- 909 North State Street, Pleasantville, Iowa 50225
- CMS Provider Number
- 165324
- Inspections on file
- 27
- Latest survey
- May 8, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Accura Healthcare Of Pleasantville, Llc during CMS and state inspections, most recent first.
Residents and family members reported significant delays in call light response times, late medication administration, and unmet care needs due to insufficient staffing. Multiple residents with intact cognition described waiting from 30 minutes to several hours for assistance, and concerns were raised about staff shortages and delays in basic services such as laundry and room cleaning. Staffing schedules showed limited coverage, and the DON acknowledged working the floor during weekends.
Several residents with limited ROM and mobility impairments did not consistently receive restorative care or therapy-recommended interventions as directed in their care plans. Documentation was often incomplete or missing, and residents reported being unable to participate in exercises or use equipment due to staff unavailability. Staff interviews confirmed the lack of a designated restorative aide, with CNAs expected to perform restorative activities but unable to do so regularly because of staffing shortages and other duties.
The facility did not maintain an effective QAPI process, leading to repeated deficiencies in areas such as abuse prevention, resident assessment, care planning, quality of care, and infection control. High staff turnover, especially in nursing leadership, contributed to ongoing issues, and the QAPI committee's efforts were insufficient to prevent recurring citations.
The facility did not report allegations of abuse and misappropriation of resident property to state authorities within the required timeframe. In one case, a resident reported missing money, but the Administrator delayed reporting while attempting to verify details with family. In another case, staff raised concerns about a former Assistant Administrator's use of two residents' trust funds, but the incident was only investigated internally and not reported. These actions were not in compliance with facility policy and regulatory requirements for timely reporting.
Surveyors found improper food storage and handling, including thawing meat at unsafe temperatures, unlabeled and unsealed food items in freezers, and persistent kitchen sanitation issues such as a leaking sink and unclean dishwashing equipment. An LPN was also observed handling a resident's food with bare hands without hand hygiene, all in violation of facility policies.
A resident with severe cognitive impairment and vision issues was left without his corrective lenses for over two months after his glasses went missing. Despite the family's repeated requests and filing a grievance, facility staff did not schedule an optometrist appointment, and the family ultimately arranged the appointment themselves.
A resident and their representative were not given the correct CMS Advanced Beneficiary Notice (ABN) form to inform them of service options and potential financial liability for non-covered services. Instead, a different form was provided, and the facility lacked a policy for ABNs. The Administrator, who managed ABNs in the absence of a social worker, relied on forms from the corporate office and believed the correct form was used.
A resident receiving hospice care with a diagnosis of dementia did not have hospice services or dementia accurately coded on multiple MDS assessments. Staff interviews revealed turnover in the MDS Coordinator position, lack of training, and outdated care plans, leading to incomplete and inaccurate resident assessments.
Two residents did not have comprehensive care plans reflecting their current needs, including one with a chronic skin condition and another on hospice care. Staff were aware of these issues, but the care plans lacked necessary updates and details, and documentation practices were inconsistent with facility policy.
A resident with depression and intact cognition, who valued family involvement in care discussions, did not have quarterly care conferences documented over a six-month period. Staff interviews confirmed that no care conferences were held or documented during this time, and there was no policy in place to ensure compliance. The resident expressed that concerns raised in previous conferences were not addressed.
Staff did not consistently change gloves between tasks during care for a resident with an indwelling catheter, and failed to disinfect a mechanical lift between uses for different residents. These actions were not in accordance with facility policies or infection control expectations as confirmed by nursing leadership.
The facility did not ensure that three CNAs completed the required 12 hours of annual in-service education, with one CNA completing less than 9 hours, another only 1 hour, and a third none at all. The DON reported that education is provided monthly and through Relias, but the Administrator noted that night shift staff often miss these sessions.
A resident with severe cognitive impairment had personal items purchased with their trust funds, but facility staff failed to follow procedures for verifying, documenting, and distributing these items. Purchased goods were left unaccounted for at the nurse's station, receipts were incomplete and unsigned, and there were discrepancies in item sizes and missing items, resulting in improper handling of the resident's funds and belongings.
The facility did not suspend or separate an employee accused of theft from resident contact during an internal investigation, allowing the employee to remain in the facility and participate in the investigation process involving two residents' trust accounts.
Two residents with severe cognitive impairment were involved in allegations of misappropriation of funds when a staff member used their trust accounts to make purchases. The facility's investigation was limited to an independent review of receipts by the Administrator, without staff interviews or proper documentation, and items purchased were not promptly verified or distributed. Discrepancies in item sizes and missing signatures on receipts were noted, and the incident was not reported to the state agency as required by policy.
Three residents experienced delays or omissions in nursing assessment and intervention following incidents such as a puncture wound from a broken wheelchair, a hot coffee spill, and a recurring sore on the scalp. In each case, staff failed to document timely assessments or provide appropriate follow-up, and care plans or facility policies did not address the residents' needs or changes in condition.
During a COVID-19 outbreak, a LTC facility failed to provide adequate PPE and did not isolate COVID-19 positive residents, leading to 26 residents testing positive. A resident with COPD and CHF was hospitalized due to COVID-19 complications. Staff reported PPE shortages and improper usage, with some working while COVID-19 positive. The facility's infection control policies were not followed, contributing to the outbreak.
A resident with moderate cognitive impairment was found on the floor with injuries after an unwitnessed fall, having been unattended for several hours. Staff interviews revealed issues with staffing levels, lack of regular checks, and delayed responses to call lights. The facility lacked a policy on bed checks, contributing to the deficiencies in care.
Facility staff failed to secure a treatment cart, leaving it unlocked and unattended in the nurse's station area, accessible to residents. The facility had 45 residents, with 30 in the front portion of the building. Interviews with staff confirmed the frequent observation of unlocked medication carts, including the narcotic drawer, accessible to staff, visitors, or residents.
The facility failed to ensure resident safety and proper care, as evidenced by a resident with cognitive impairment who was left unattended for hours after a fall, and another resident who did not receive requested medication due to staff miscommunication. Additionally, issues with infection control practices and staff management, such as inadequate PPE and staff taking breaks together, were noted.
The facility failed to respect residents' rights, as evidenced by an LPN's refusal to administer requested medications separately, leaving a resident in pain. Another resident was left in soiled clothing for hours, and meals were served on disposable ware post-COVID-19 outbreak, undermining dignity.
The facility failed to provide scheduled bathing services for three residents and appropriate perineal care for a resident with quadriplegia, due to staffing shortages. Residents experienced missed baths and inadequate hygiene care, leading to cleanliness issues and irritation. Staff interviews confirmed that CNAs were often unable to adhere to care schedules due to being assigned additional duties.
The facility failed to maintain accurate health records and medication administration for two residents. One resident was left in wet clothing without proper documentation of care, while another experienced misdocumentation in medication administration, with confusion over who administered the medication. These issues highlight deficiencies in record-keeping and adherence to care protocols.
The facility inaccurately assessed a resident's behavior in the MDS following an incident where a resident shoved another, causing a fall. The MDS indicated no behavioral symptoms, contrary to the event. Additionally, the facility misreported restraint use for six residents, despite confirmation that no restraints were used.
The facility failed to implement care plans for three residents, resulting in unmet needs. A resident with severe cognitive impairment refused scheduled baths without alternative interventions being documented. Another resident with hemiplegia received baths as planned, while a third resident with moderate cognitive impairment had a care plan for sponge baths if needed, but there was no documentation of refusals or alternative methods being used.
The facility staff failed to properly administer medications for three residents, leading to unlabeled medications being stored improperly, medications being left unattended, and a resident experiencing unmanaged pain due to inaccessible medication. An LPN admitted to storing medications in a cart drawer, a CNA reported unattended medications, and a resident's grievance highlighted issues with medication placement by the ADON.
A facility failed to follow physician orders for a resident's medication administration. The MAR indicated that Memantine HCL and Mirtazapine were documented as administered, but Olanzapine was missing. An LPN attempted to administer medications to another resident who refused, yet the LPN signed out the administration on the MAR. The LPN later corrected the MAR, acknowledging the resident's refusal of morning medications.
A facility failed to provide restorative services to maintain or improve ROM and mobility for a resident. The resident, who needed moderate assistance with daily activities, reported that staff did not perform ROM exercises, which she preferred to achieve her goal of returning home. Interviews with CNAs confirmed the lack of restorative services, and the facility was found to lack a restorative policy or procedure.
The facility failed to employ a qualified Activities Director, resulting in limited and repetitive activities for residents. Activity calendars for April and May 2024 showed a lack of diverse options, with many days having no activities. Residents and staff expressed dissatisfaction, noting infrequent and unscheduled activities. The facility's assessment highlighted the need for a full-time AD, but this was not met, leading to inadequate psycho/social/spiritual support for residents.
The facility failed to maintain resident dignity during meals, with CNAs standing and feeding residents in a rushed manner due to staffing shortages. Additionally, a resident's disruptive behavior, including yelling profanities, affected the dining experience for others. Despite complaints, the administration did not address the issue, contrary to the facility's person-centered dining policy.
The facility failed to provide a comprehensive activities program, impacting residents' well-being. Activity calendars showed gaps and repetitive options like Bingo, with residents and staff expressing dissatisfaction. The absence of an Activity Director and inconsistent efforts by staff contributed to the deficiency.
The facility failed to maintain a homelike dining environment as a resident with cognitive impairments repeatedly yelled profanities during meals, disrupting others. Despite complaints from other residents, the administrator and corporate nurse did not express concern, although the team is discussing options. The facility's policy emphasizes a cheerful dining atmosphere, which was not achieved.
The facility failed to provide appropriate meal portions for residents on pureed and mechanical soft diets, with staff misinterpreting dietary conversion charts and not preparing enough food. Additionally, residents were not informed of meal options or provided with alternative choices, as menus were not posted in advance. Facility policies on portion control and menu display were not adhered to.
The facility failed to maintain safe and appetizing food temperatures during meal service. A cook recorded the Ham Loaf temperature below the required 135°F, and lettuce was served at room temperature, contrary to the facility's policy. The Administrator confirmed that staff should follow the policy for food service temperatures.
The facility failed to maintain sanitary practices in the food preparation area. Staff F was observed with an uncovered mustache and goatee, and his head cap did not contain all of his hair. He handled food with bare hands, including slicing tomatoes, filling a dressing dispenser, and handling lettuce and bread. The facility's policy required the use of gloves and utensils to avoid bare hand contact with food, which was not followed.
A facility failed to timely notify a resident's emergency contact following an emergency evacuation and transfer to another facility. The resident was evacuated early in the morning and transferred by mid-morning, but the emergency contact was not informed until the afternoon. Hospice staff assisting with the relocation expressed frustration over the communication delay. The facility's administrator acknowledged the expectation for timely notification, but no policy was provided.
The facility failed to complete discharge summaries for two residents, leading to a deficiency in communication at discharge. One resident, managed by PACE, lacked a discharge summary despite having moderately impaired cognition. Another resident, transferred for an emergency evacuation, also did not have a completed discharge summary. The facility acknowledged these oversights.
A facility failed to include a resident and their family in quarterly care plan meetings, as required. The resident, with moderate cognitive impairment and multiple diagnoses, had a care plan that emphasized family involvement. However, the responsible party was unaware of the meetings and had not been invited. The new MDS Coordinator could not find documentation of past meetings and noted the absence of a systematic process for involving residents and families.
A resident with multiple health conditions received improper medication administration, including an incorrect Thiamine dose and delayed meal after insulin injection. The CMA failed to instruct the resident to rinse their mouth after using an inhaler, violating professional standards and facility policies.
A resident with a suprapubic catheter was observed with the catheter bag improperly managed, dragging on the floor and under the wheelchair, increasing the risk of infection. The facility lacked a specific policy for catheter bag management, although a general catheter care policy existed. The resident, with a history of multiple health issues, was being treated for a urinary tract infection.
Delayed Call Light Response and Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and unmet care needs. Resident Council Meeting notes and grievance forms documented multiple complaints from residents and family members regarding long wait times for call light responses, delays in receiving coffee, late medication administration, and untimely blood sugar checks. Four out of seven interviewed residents with intact cognition reported waiting between 30 minutes to two hours for staff to respond to their call lights, with one resident stating he waited several hours for requested medication and treatments. Residents also reported concerns about staffing shortages and delays in laundry and room cleaning. Staffing schedules provided by the DON indicated that each shift was staffed with two CNAs and one nurse or CMA per hall, but residents and family members continued to report unmet needs and delays in care. The DON confirmed that she sometimes worked the floor when on call during weekends. The documented concerns and interviews demonstrate that the facility did not ensure adequate staffing levels to provide timely care and meet residents' needs as required.
Failure to Provide Consistent Restorative Care and Follow Therapy Recommendations
Penalty
Summary
The facility failed to provide appropriate restorative care and follow therapy recommendations for four residents with limited range of motion (ROM) and mobility impairments. Documentation and care plans indicated that residents with conditions such as multiple sclerosis, hemiplegia, arthritis, and spinal stenosis were to receive specific restorative nursing programs (RNP), including passive and active ROM exercises, ambulation, and use of exercise equipment. However, records showed inconsistent or missing documentation of these interventions, with many days left blank or marked as not applicable, and progress notes often stating that residents did not participate in RNPs during the review periods. Observations and interviews with residents revealed that some residents expressed a desire to participate in restorative activities, such as walking or using exercise equipment, but were unable to do so due to lack of staff availability or supervision. Residents reported waiting for staff assistance to perform exercises or use equipment, and in some cases, only received restorative interventions a few times per month despite care plan directives for more frequent activity. Staff interviews confirmed that there was no designated restorative aide, and that CNAs were expected to perform restorative activities as part of their regular duties, but often could not due to staffing shortages and competing responsibilities. Further interviews with facility leadership and therapy staff indicated a lack of clear assignment and accountability for restorative care. Therapy staff expected nursing to follow through on therapy discharge recommendations, but nursing staff reported that restorative programs were not consistently implemented or documented. The facility's policy required individualized restorative plans and monthly summaries, but these were not consistently in place or up to date. The absence of a dedicated restorative aide and reliance on CNAs to perform restorative care contributed to the inconsistent delivery and documentation of required interventions for residents with limited ROM and mobility needs.
Failure to Implement Effective QAPI Process Resulting in Repeat Deficiencies
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process to address previously identified quality deficiencies, resulting in repeated citations across multiple surveys and complaint investigations. Review of the Department of Inspections, Appeals and Licensing (DIAL) website and CMS-2567 reports revealed that the facility had recurring deficiencies in areas such as abuse prevention, resident assessment, care planning, quality of care, and infection control. These deficiencies were cited during annual surveys and complaint investigations over several years, indicating a pattern of unresolved issues. The facility also had a 1-star staffing rating for the reported quarter, attributed to high staff turnover, particularly in nursing leadership positions including the DON, ADON, and MDS nurse. Interviews with the Administrator confirmed awareness of the repeat deficiencies and acknowledged that the entire nursing department had turned over earlier in the year, with delays in filling key positions. The QAPI committee reportedly met quarterly and identified areas for improvement, but the persistent recurrence of deficiencies suggests that the QAPI process was not effective in ensuring sustained compliance. The facility's QAPI plan described a systematic approach to quality improvement, including root cause analysis and monitoring, but the ongoing repeat citations demonstrate that these processes were not successfully implemented or maintained.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or misappropriation of resident property to the Iowa Department of Inspections, Appeals and Licensing (DIAL) within the required 24-hour timeframe for three residents. In one case, a resident with chronic respiratory failure and diabetes, who was cognitively intact, reported missing money from her purse shortly after admission. The inventory sheet completed at admission did not list a purse or money, and staff interviews confirmed the purse was not initially observed. The resident reported the missing money to a registered nurse, who notified the Administrator. The Administrator delayed reporting the incident to DIAL, waiting to verify the amount of money with the resident's family before initiating an investigation and contacting authorities. In another incident, allegations were made that a former Assistant Administrator used two residents' trust funds to purchase items for herself. Staff reported concerns that purchased items were not properly checked in or accounted for, and receipts were not signed to validate delivery to the residents. The facility conducted an internal investigation by reviewing receipts and checking the residents' rooms for the items, but did not report the allegations to DIAL. The Administrator confirmed that the residents involved were not cognitively able to express their wants and needs, and law enforcement was not notified as there was no missing money according to the facility's findings. The facility's own policy, as well as state and federal regulations, require that all allegations of abuse, neglect, exploitation, or misappropriation be reported to DIAL within 24 hours, and in some cases within 2 hours, depending on the severity of the incident. Despite these requirements, the facility did not report the incidents within the mandated timeframe, as confirmed by staff and Administrator interviews and review of facility documentation. The failure to report was attributed to the Administrator's decision to first verify details with family members or to conduct an internal investigation before notifying authorities.
Deficient Food Storage, Handling, and Kitchen Sanitation
Penalty
Summary
Surveyors observed multiple failures in food storage, handling, and kitchen sanitation. A refrigerator/freezer labeled as non-functional was found to contain three beef roasts thawing overnight, with the internal temperature reading 56°F, well above the safe threshold. The roasts were visibly bloated, and staff could not confirm how long the temperature had been elevated. Numerous items in chest freezers were found unlabeled, undated, and unsealed, including bags of cooked eggs, French fries, poultry meat, carrots, and tater tots. Spilled food was present inside the freezer, and staff interviews confirmed that proper labeling, dating, and sealing procedures were not consistently followed. Additionally, the dishwashing unit trap had significant debris buildup that was not cleared over multiple days. Further inspection revealed a leaking sink pipe under the kitchen sink, with a large bucket of foul-smelling water and black organic buildup, which had reportedly been an issue for months. Staff interviews indicated that the problem had been reported to management but was not resolved. In the dining area, an LPN was observed handling a resident's food with bare hands without hand hygiene before or after, contrary to facility policy and staff training. Policies reviewed required all foods to be covered, labeled, and dated, and mandated the use of barriers such as gloves when handling resident food, but these were not followed in practice.
Failure to Timely Replace Resident's Corrective Lenses
Penalty
Summary
A resident with diagnoses of non-Alzheimer's dementia and amaurosis fugax, and a severely impaired cognitive status, required corrective lenses for vision. The resident was found wearing glasses that did not belong to him, and it was documented that his own glasses were missing. The facility's records show that the administrator searched for the missing glasses but was unable to locate them. Despite a grievance being filed by the resident's family in December regarding the missing glasses, the facility did not schedule an optometrist appointment to replace them in a timely manner. The family reported that they had informed facility staff about the missing glasses prior to the documented grievance date and had requested an appointment for replacement eyewear, but the facility failed to act on this request. After waiting for over two months without resolution, the family scheduled the necessary doctor's appointment themselves. The administrator later acknowledged that there was no documentation explaining why the facility did not arrange the appointment, but believed it was due to family preference.
Failure to Provide Correct Medicare Non-Coverage and ABN Forms
Penalty
Summary
The facility failed to provide the appropriate Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) and Advanced Beneficiary Notice (ABN) forms to a resident regarding service options and potential financial liability for non-covered services. Record review showed that the resident and/or their representative received the NOMNC (CMS form 10123) with information on the right to appeal, but instead of the required ABN (CMS form 10055), the facility provided a different form (CMS form 10124-DENC), which did not indicate the option to receive or decline continued skilled services. Interviews with the Administrator revealed that there was no social worker at the facility, and the Administrator was responsible for handling ABNs, relying on forms provided by the corporate office. The Administrator believed the correct form was used but confirmed there was no facility policy for ABNs.
Inaccurate MDS Assessment and Documentation for Hospice Resident
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for a resident who was admitted to hospice care with a diagnosis of dementia. Clinical record review showed that the resident was admitted to hospice services with dementia, and the Significant Change MDS correctly indicated hospice level of care and listed dementia among active diagnoses. However, subsequent Quarterly MDS assessments did not reflect hospice services or the dementia diagnosis, and the section for special treatments, procedures, and programs was left blank. The resident's cognitive status was documented as severely impaired, but the required updates to the MDS were not made to accurately reflect the resident's current condition and services received. Interviews with facility staff revealed that there was a lack of continuity and oversight in the MDS assessment process. The MDS Coordinator position experienced turnover, and the new coordinator reported insufficient training and support, as well as outdated care plans and inaccurate MDS documentation. The facility's policy required accurate assessments by qualified staff, but this was not followed, resulting in incomplete and inaccurate resident assessments.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required by policy and regulatory standards. For one resident with diabetes and a history of skin cancer, the care plan did not include information about a chronic skin condition or a sore on the top of the head, despite multiple progress notes and interviews indicating the presence of a recurring, inflamed mole. Staff and the resident reported the area had been treated previously and continued to cause discomfort, but this was not reflected in the care plan. Documentation showed that staff were aware of the issue, applied treatments as needed, and eventually scheduled a dermatology appointment, but the care plan remained incomplete regarding this ongoing skin concern. For another resident with severe cognitive impairment and multiple comorbidities, including heart failure, chronic kidney disease, and dementia, the care plan was not updated in a timely manner to reflect the initiation of hospice care. There were discrepancies in physician order dates, hospice admission documentation, and the timing of care plan updates. Interviews with staff revealed that care plans and MDS assessments were not consistently accurate or current, and that the process for updating care plans was not well managed, with various staff members making entries without a clear system. The facility's own policy requires that comprehensive, person-centered care plans be developed and updated to address all identified needs and services, with measurable objectives and timeframes. However, the care plans for these two residents did not meet these requirements, as they lacked critical information about current conditions and services, and were not revised in accordance with changes in the residents' status or care needs.
Failure to Hold and Document Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were held at least quarterly and that follow-up on concerns raised during these conferences was documented for a resident with a diagnosis of depression and intact cognition. The resident's Minimum Data Set (MDS) indicated that having family or a close friend involved in care discussions was very important. While the electronic health record showed a care conference note with family and the resident in attendance on one occasion, there was no documentation of any care conferences held over a six-month period. Both the electronic and paper records lacked evidence of care conferences or follow-up on concerns discussed during this time. Interviews with the resident revealed dissatisfaction with the care conference process, stating that concerns raised were not addressed. Staff interviews confirmed that the MDS nurse was responsible for arranging care conferences but none were held during her tenure, and there was no policy in place for care conferences. The administrator and regional clinical director acknowledged the absence of care conference records and documentation, and confirmed that the facility was not in compliance with the requirement to hold and document quarterly care conferences.
Failure to Follow Infection Control Protocols During Resident Care and Equipment Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols during resident care and equipment handling. For one resident with a history of cerebrovascular accident, hemiplegia, and neurogenic bladder with an indwelling catheter, staff did not consistently change gloves between tasks. During observed care, a CNA changed gloves after cleaning the resident's peri-area but continued to wear the same gloves while touching the resident's clothing and assisting with other tasks, such as placing a blanket and handing the resident a grabber device. The staff also did not perform hand hygiene immediately after glove removal, as one staff member only applied hand sanitizer after removing gloves and reaching into her uniform pocket. Facility policy required gloves to be replaced when contaminated and for staff to change gloves before and after care or when moving from dirty to clean tasks. Additionally, staff failed to disinfect a mechanical lift between uses. After transferring a resident, a CNA pushed the lift into the hallway without disinfecting it, and another staff member subsequently used the same lift for a different resident without cleaning it. Facility policy stated that equipment should be cleaned and sanitized prior to use in other areas. Interviews with nursing staff and the DON confirmed the expectation that equipment such as mechanical lifts be disinfected before and after use, but this was not observed in practice.
Failure to Ensure Required CNA In-Service Education
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) completed the required minimum of 12 hours of annual in-service education for 3 out of 4 sampled CNAs who had been employed for more than one year. Review of the employee roster and education transcripts showed that one CNA completed 8.95 hours, another completed 1.0 hour, and a third completed 0 hours of in-service education during the review period. The Director of Nursing stated that mandatory in-services are held monthly and education courses are available through Relias, with the expectation that staff complete at least 12 hours of education each year. The Administrator noted that night shift staff often do not attend meetings or in-service training, making it difficult to ensure their participation.
Failure to Properly Handle Resident Funds and Property
Penalty
Summary
Facility staff failed to properly handle a resident's funds, resulting in a deficiency related to the protection of resident property. A resident with severe cognitive impairment and multiple diagnoses, including dementia and schizophrenia, had items purchased using their trust account. The purchases were made by a former Assistant Administrator, who did not follow established procedures for verifying and distributing the items. Specifically, the purchased items were left in bags at the nurse's station for weeks, and no receipts were provided to CNAs for verification. There were no signatures on the receipts to confirm that the items were delivered to the resident, and staff repeatedly requested the receipts to complete the check-in process. The facility conducted an internal investigation after allegations arose that the former Assistant Administrator may have purchased items for herself using resident funds. The investigation involved reviewing receipts and resident belongings, but the process lacked thorough staff interviews and did not include reporting the allegations to the state regulatory agency. The receipts provided were incomplete, missing identifying information, and lacked signatures from staff or the resident to validate the purchases. Additionally, there were discrepancies between the sizes of clothing purchased and the sizes typically worn by the resident, and some items listed on receipts could not be accounted for in the resident's belongings. Staff interviews confirmed that the resident typically wore XL or 2XL clothing, but several items purchased were in smaller sizes, and some items such as slippers were not observed in the resident's room. The process for purchasing and distributing items for residents who could not communicate their needs was not consistently followed, and inventory procedures were not properly documented. The lack of proper documentation, verification, and accountability in handling the resident's funds and belongings led to the deficiency.
Failure to Separate Accused Employee During Abuse Investigation
Penalty
Summary
The facility failed to implement immediate protective measures after receiving allegations of potential theft by an employee involving two residents' trust accounts. Upon being notified of the allegations, the facility initiated an internal investigation by reviewing receipts and checking account statements, and by physically verifying the purchased items in the residents' rooms. However, the employee accused of the misconduct was not suspended or separated from resident contact during the investigation. Instead, the employee remained in the facility and participated in the investigation process, including assisting the facility Administrator in identifying items in the residents' rooms. The facility's policy required immediate action to prevent further potential abuse by separating the accused employee from all residents during an investigation, either by suspension or reassignment. Despite this, the accused employee continued to have access to the facility and was not restricted from resident contact while the investigation was ongoing. The facility's census at the time was 45 residents, and the failure to follow policy was confirmed through interviews, review of the abuse investigation, and policy documentation.
Failure to Thoroughly Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The facility failed to conduct a thorough investigation into two allegations of misappropriation of resident funds involving two residents with severe cognitive impairment. Both residents had significant medical and cognitive conditions, including dementia, schizophrenia, and hemiplegia, which limited their ability to express their needs or preferences. The allegations centered on purchases made from the residents' trust accounts by a former Assistant Administrator, with concerns raised by staff that items purchased may not have been delivered to the intended residents and that receipts were not properly managed or verified. The facility's internal investigation primarily involved the Administrator independently reviewing receipts and comparing them to items found in the residents' rooms, without interviewing relevant staff or obtaining written witness statements. Staff interviews revealed that purchased items remained in bags at the nurse's station for weeks, and staff repeatedly requested receipts to verify and distribute the items, but these were not provided in a timely manner. There were also discrepancies in the sizes and types of items purchased compared to the residents' known needs, as reported by multiple CNAs familiar with the residents' care routines. Documentation provided by the facility included partial and reprinted receipts, which lacked clear identification of the place of purchase and did not include signatures from the purchaser, residents, or staff to confirm receipt and delivery of items. The facility Administrator did not report the allegations to the state regulatory agency as required by policy, and did not interview staff or preserve physical evidence as outlined in the facility's abuse investigation protocols. The investigation was completed without comprehensive documentation or staff involvement, and the facility failed to follow its own policies for reporting and investigating allegations of abuse or misappropriation.
Failure to Assess and Intervene for Resident Injuries and Skin Conditions
Penalty
Summary
The facility failed to complete timely assessments and provide appropriate interventions for three residents following incidents that required nursing attention. One resident, with a history of heart failure, renal insufficiency, diabetes, and limited mobility, sustained a puncture wound to the right lower calf from a broken wheelchair. Despite the resident and a CNA reporting the injury, no nursing assessment was performed for over 12 hours, and the wound was not addressed until the following day. The nurse and ADON were unaware of the injury, and the maintenance department was not notified until after the surveyor's inquiry. The care plan required staff to monitor skin and report issues, but this was not followed, resulting in delayed wound care and equipment repair. Another resident, who was severely cognitively impaired and at risk due to visual impairment and confusion, spilled hot coffee on her chest. Although the incident was reported and the physician was notified, there was no documented evidence of ongoing nursing assessment or monitoring of the affected skin area as required by the facility's process. The only documentation available was the initial incident report, and the facility acknowledged that if further assessments were completed, they were not documented. The facility also lacked policies for resident assessments or nursing documentation. A third resident, with a history of diabetes and previous skin cancer, reported a recurring sore on the top of the head. The care plan did not address this chronic skin issue, and there was no documentation of skin assessments or incident reports related to the sore. Although the resident and staff reported the issue to physicians and nurses, and treatments were attempted, there was no referral to dermatology or consistent documentation of the condition until after the surveyor's inquiry. The facility also lacked a policy for change in condition, contributing to the lack of timely assessment and intervention.
Inadequate PPE Usage and COVID-19 Outbreak in LTC Facility
Penalty
Summary
The facility failed to provide a safe environment to prevent the transmission of communicable diseases and infections, specifically during a COVID-19 outbreak. Staff did not appropriately wear Personal Protective Equipment (PPE), and PPE was not made available for staff caring for COVID-19 positive residents. This led to a significant outbreak where 26 out of 45 residents tested positive for COVID-19. Resident #16, who had a history of Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF), became COVID-19 positive and was transferred to the hospital due to shortness of breath and low oxygen levels. Staff interviews revealed that PPE, such as gowns and eye protection, was not consistently available or used during the outbreak. Staff reported that they were instructed to work even when COVID-19 positive, with only N95 masks provided, and that gowns and eye protection were unavailable until late in the outbreak. Staff also indicated that residents who tested positive were not isolated properly, and there was a lack of signage to indicate isolation precautions. The Director of Nursing (DON) and other staff acknowledged the lack of PPE and the failure to isolate COVID-19 positive residents. The DON admitted that PPE was not utilized effectively and that there was skepticism about its effectiveness in preventing transmission. The facility's policies on infection control and COVID-19 outbreak management were not followed, contributing to the spread of the virus among residents and staff.
Removal Plan
- All facility staff were educated on the appropriate use of personal protective equipment in the facility.
- All residents on isolation have isolation carts stocked and available.
- Competencies were completed with all staff currently at the facility. All staff not present will have competencies completed prior to their next shift.
- The facility initiated on-going audits of isolation and personal protective equipment three times weekly.
- Any concerns will be reported to the administrator immediately and addressed in facility QA.
Inadequate Staffing and Rounding Leads to Resident Neglect
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure the safety and care of residents, as evidenced by the incident involving Resident #9. Resident #9, who had moderate cognitive impairment and required maximal assistance with dressing and moderate assistance with toileting, was found on the floor with a bruise and a laceration on the head after an unwitnessed fall. The resident reported being on the floor for a significant portion of the night without assistance, as no staff checked on her between 3:30 AM and 8:30 AM. The resident was unable to reach her call light and had been yelling for help without response. The facility's investigation revealed that the resident was last seen at 3:30 AM and was found at 8:30 AM, indicating a lack of regular checks and rounds by the staff. Interviews with staff members highlighted issues with staffing levels and the completion of rounds. Staff B, an LPN, found Resident #9 on the floor and noted that the CNA's working that day did not complete walking rounds, which have since been mandated to be signed off. Staff members reported that the facility was short-staffed, particularly on weekends, and that all nursing staff sometimes took breaks together, leaving residents unattended. The Director of Nursing confirmed that no CNA had entered Resident #9's room from 3:30 AM until the resident was found at 8:30 AM, and expressed a desire for more frequent rounding, ideally every two hours. Additional concerns were raised by other residents and staff regarding the timeliness of call light responses and the provision of care. Resident #4 reported waiting up to 30 minutes for assistance after activating the call light, and staff members confirmed delays in responding to call lights due to staffing issues. The facility's policy required call lights to be within reach and answered promptly, but this was not consistently achieved. The facility lacked a policy on bed checks or rounds, contributing to the deficiencies in care and oversight.
Unsecured Treatment Cart in Facility
Penalty
Summary
The facility staff failed to maintain a locked and secured treatment cart, as observed on September 22, 2024, at 12:47 p.m. The treatment cart was positioned along the wall in the nurse's station area, beside the resident's paper chart rack, and was left unlocked and unattended, making it accessible to all residents in the front of the building. The facility had a census of 45 residents, with 30 residing in the front portion of the building. During interviews, the Administrator confirmed the layout of the building and the location of the residents. Staff C, a Certified Nursing Assistant (CNA), confirmed observing unlocked, unattended medication carts with drawers left open, including the narcotic drawer, accessible to any staff, visitors, or residents. Staff E, another CNA, also confirmed frequently observing unlocked and unattended medication carts.
Deficiencies in Resident Care and Staff Management
Penalty
Summary
The facility failed to administer care in a manner that ensured the safety and well-being of its residents, as evidenced by the incident involving a resident with moderate cognitive impairment who experienced an unwitnessed fall. The resident was found on the floor with a head injury and had been there for several hours without assistance, as staff failed to conduct regular checks between 3:30 AM and 8:30 AM. The resident was unable to reach the call light and had attempted to clean up the blood from her injury. The facility's investigation confirmed that the resident was last seen at 3:30 AM and was not checked on until she was found on the floor at 8:30 AM, highlighting a significant lapse in monitoring and care. Another deficiency was noted in the administration of medication to a resident who had no cognitive impairment. The resident reported that a nurse attempted to administer both Tramadol and Tylenol together, despite the resident's request to take them separately. The nurse left the room without providing the requested medication, and it was only after another nurse intervened that the resident received the Tramadol. The Director of Nursing (DON) and the Administrator were aware of the incident but did not conduct a timely investigation or address the grievance appropriately, indicating a lack of proper communication and follow-up on resident concerns. The report also highlighted issues with infection control practices and staff management. Staff reported a lack of proper personal protective equipment (PPE) and inadequate training on Enhanced Barrier Precautions (EBP). Additionally, there were concerns about staff taking breaks together, leaving the facility understaffed at times. The Infection Preventionist (IP) was unable to perform her duties effectively due to being overworked and lacking access to necessary computer programs for tracking infections. The Administrator acknowledged these issues but had not taken sufficient steps to address them, contributing to the facility's failure to maintain a safe and effective care environment.
Deficiencies in Resident Care and Dignity
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence and self-determination, as evidenced by multiple incidents involving staff interactions with residents. One incident involved a resident who requested specific pain medications separately, but the LPN insisted on administering them together, leading to a verbal altercation. The resident, who was paralyzed and experiencing back pain, was left without the requested medication for an extended period, causing distress and offense. The LPN did not follow the resident's request and failed to document the administration of medication properly. Another deficiency was observed with a resident at risk for skin breakdown due to incontinence. The resident was left with a large wet area on their clothing for an extended period after lunch, indicating a failure to provide timely personal care. The CNA involved did not change or reposition the resident as expected, leaving the resident in a state of undignified care. This neglect was contrary to the facility's policy of checking and changing residents at least every two hours. Additionally, the facility continued to serve meals on Styrofoam plates with plastic silverware even after the COVID-19 outbreak had ended, which was not in line with the residents' rights to be treated with dignity. The dietary staff and management did not update their practices following the outbreak, leading to a continued use of disposable dining ware, which was not necessary at the time of the survey. These actions collectively demonstrate a pattern of neglecting residents' rights and failing to provide a dignified living environment.
Deficiencies in Bathing and Perineal Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide bathing services according to the individual schedules and preferences of three residents. Resident #2, who is severely cognitively impaired, was scheduled for baths twice a week but refused on multiple occasions without alternative interventions being offered. Resident #4, who is cognitively intact, expressed a preference for two baths a week but was observed with oily hair, indicating a lack of cleanliness. Resident #5, with moderately impaired cognitive skills, was scheduled for baths twice a week, but staff interviews revealed that staffing issues often prevented adherence to these schedules. Additionally, the facility failed to provide appropriate perineal care for Resident #10, who is cognitively intact and has a diagnosis of traumatic spinal cord dysfunction and quadriplegia. The resident reported that night shift CNAs did not properly cleanse her perineal and gluteal regions, leading to irritation and itching. This concern was documented in Resident Council minutes and a grievance form, highlighting ongoing issues with the quality of care provided during the night shift. Interviews with staff members confirmed that the facility's failure to adhere to residents' bathing schedules and requests was due to staffing shortages. CNAs reported being pulled to perform other duties, which limited their ability to provide scheduled baths. The facility's policy required two baths per week for each resident, but this standard was not consistently met, as evidenced by the observations and interviews conducted during the survey.
Deficiencies in Documentation and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate electronic health records for two residents, leading to deficiencies in care documentation. For Resident #20, the facility's records indicated that the resident was incontinent of urine, as documented by Staff H, a CNA, without actually checking the resident. Observations revealed that Resident #20 had a large wet area on his clothing, which was not addressed by Staff H, who left the resident in this condition. This discrepancy between the observed condition and the documented record highlights a failure in accurately documenting the resident's care needs and actions taken. In the case of Resident #10, there was a failure in the medication administration process. The resident, who had no cognitive impairment, reported that Staff G, an LPN, attempted to administer both Tramadol and Tylenol together, despite the resident's request to receive them separately. Staff G documented the administration of Tramadol in the MAR, although it was actually administered by Staff I, an RN, after the resident's initial refusal. This misdocumentation and confusion over who administered the medication indicate a lack of proper communication and adherence to medication administration protocols. The Director of Nursing (DON) and other staff interviews confirmed these discrepancies, acknowledging that the documentation did not reflect the actual care provided. The facility's policies require accurate documentation of care and medication administration, which were not followed in these instances. These deficiencies in record-keeping and medication administration could potentially impact the quality of care provided to the residents.
Inaccurate Resident Assessment and Restraint Coding
Penalty
Summary
The facility failed to provide an accurate assessment of a resident's behavior during the observation period of the Minimum Data Set (MDS). Specifically, an incident occurred where a resident shoved another resident against the wall, resulting in a fall. However, the MDS assessment completed shortly after the incident inaccurately indicated that the resident showed no signs of delirium, mood, or behavioral symptoms directed towards others. Additionally, the facility inaccurately coded their 802 Matrix related to restraints, identifying six residents as using restraints when an email from the Clinical Nurse Specialist confirmed that no residents utilized restraints in the facility.
Failure to Implement Care Plans for Residents
Penalty
Summary
The facility failed to implement care plans for three residents, leading to deficiencies in meeting their needs. Resident #2, who was severely cognitively impaired, had a care plan that required assistance with bathing twice a week. However, the resident refused baths on multiple occasions without any documented alternative interventions, such as bed baths or changes in schedule, being attempted. This lack of follow-up on refusals indicates a failure to adhere to the care plan and address the resident's hygiene needs. Resident #4, who was cognitively intact but had hemiplegia, received baths as scheduled without refusals, indicating compliance with the care plan. In contrast, Resident #5, who had moderately impaired cognitive skills and required substantial assistance, had a care plan that included sponge baths if full baths were not tolerated. Despite receiving baths on scheduled days, there is no documentation of refusals or the need for alternative bathing methods, suggesting that the care plan was not fully implemented or monitored for effectiveness.
Medication Administration Deficiencies
Penalty
Summary
The facility staff failed to adhere to professional standards of practice in medication administration for three residents. For Resident #10, a Licensed Practical Nurse (LPN) was observed removing medication cups from a cart, which were not labeled with the resident's name or the actual medication present. The LPN admitted to placing the medications in the cart's top drawer after the resident refused them before lunch, a practice confirmed by the Clinical Nurse Specialist. Additionally, a Certified Nursing Assistant (CNA) reported that nursing staff often left medications unattended on dining room tables and bedside stands. Resident #1 was found to have medication under his bed, indicating non-compliance with prescribed doses. The Environmental Services Supervisor confirmed finding a pill at the foot of the bed and reported it to the charge nurse. She also observed a nurse leaving medications in an unknown resident's room and found pills scattered throughout the building. For Resident #21, who had a diagnosis of Amyotrophic Lateral Sclerosis and chronic pain, a grievance was filed after the Assistant Director of Nursing (ADON) left medications on the bedside table out of reach, resulting in a pain pill being lost in the bed. The resident reported the issue, which was resolved, but the incident left her in pain overnight until the pill was found the next morning.
Failure to Follow Physician Orders in Medication Administration
Penalty
Summary
The facility failed to follow physician orders for a resident, leading to a deficiency in medication administration. The Medication Administration Record (MAR) for the resident indicated that Memantine HCL and Mirtazapine were documented as administered, but Olanzapine was absent from the medication cart. During an observation, it was confirmed that all three medications were documented as administered, despite the absence of Olanzapine. This discrepancy was acknowledged by the Clinical Nurse Specialist. Further observations revealed that a Licensed Practical Nurse (LPN) attempted to administer crushed medications to another resident, who refused to take them. Despite the refusal, the LPN signed out the administration of the medications on the MAR. The LPN later admitted that the resident refused the morning medications, but she failed to correct the MAR initially. The LPN eventually updated the MAR to reflect the proper documentation, acknowledging that the resident did take the noon medications after some time, but not the morning ones.
Failure to Provide Restorative Services for Resident
Penalty
Summary
The facility failed to provide restorative services to maintain or improve the range of motion (ROM) and mobility for a resident, as observed during a survey. Resident #5, who required moderate assistance with toileting hygiene and upper body dressing, reported that staff did not perform ROM exercises, which she preferred as part of her goal to return home. Interviews with two Certified Nursing Assistants (CNAs) confirmed the lack of restorative services for residents. Additionally, an email from the Clinical Nurse Specialist revealed that the facility lacked a restorative policy or procedure. The Clinical Nurse Specialist and the Director of Nursing acknowledged that the facility's restorative program required restructuring and appropriate follow-through.
Lack of Activities Director Leads to Insufficient Resident Engagement
Penalty
Summary
The facility failed to employ a qualified Activities Director (AD), resulting in a lack of diverse and engaging activities for residents. The facility's activity calendars for April and May 2024 showed limited and repetitive activities, such as Bingo, shopping, and crafts, with several days having no activities at all. Interviews with residents and staff revealed dissatisfaction with the current activity offerings, noting that activities were infrequent, lacked variety, and often did not occur at scheduled times. The facility's assessment indicated the need for a full-time AD and various activities to support residents' psycho/social/spiritual needs, but these were not being met. Residents expressed their dissatisfaction with the lack of music and other preferred activities, and staff confirmed the absence of an AD. The facility administrator acknowledged the lack of a completed activity calendar for several months and cited water damage as a reason for the missing calendars. Nursing staff attempted to fill the gap by organizing activities when possible, but these efforts were inconsistent and insufficient. The Director of Nurses and other staff members confirmed the need for an AD to ensure residents have access to meaningful activities.
Lack of Dignity in Dining Experience
Penalty
Summary
The facility failed to uphold the dignity of residents during dining experiences in the main dining room, as observed during three meals. Certified Nursing Assistants (CNAs) were seen standing and walking around the table while feeding residents, rather than sitting and providing individualized attention. This practice was attributed to staffing shortages, with only one or two staff members available to assist multiple residents, leading to a rushed and impersonal feeding process. Interviews with staff confirmed that this method was used to ensure timely feeding, despite the lack of dignity it afforded the residents. Additionally, the dining experience was disrupted by a resident who repeatedly yelled profanities and made loud noises throughout meals. This behavior was noted to be ongoing and had been a concern for other residents, who expressed discomfort and a desire to sit elsewhere. Despite these complaints, the facility's administrator did not perceive the behavior as problematic, citing the need to avoid isolating the disruptive resident. The facility's policy emphasized a person-centered dining approach, aiming for a cheerful and respectful atmosphere, which was not reflected in the observed dining experiences.
Deficiency in Resident Activities Program
Penalty
Summary
The facility failed to provide a comprehensive activities program that catered to the interests and needs of its residents, impacting their physical, mental, and psychosocial well-being. The activity calendars for April and May 2024 showed significant gaps, with multiple days lacking any scheduled activities and others offering repetitive or singular options like Bingo, shopping, or crafts. Interviews with residents and staff revealed dissatisfaction with the limited variety and frequency of activities, with some residents expressing a lack of engagement and interest in the available options. The absence of an Activity Director further exacerbated the situation, as staff struggled to fill the gap by occasionally bringing in pets or children, but these efforts were inconsistent and insufficient. The facility's administration acknowledged the lack of a structured activities program, citing issues such as water damage and the absence of an Activity Director as contributing factors. Despite having a job description for a Director of Life Enrichment, which outlined the need for a diverse and daily activities program, the facility failed to implement these guidelines. The facility assessment from January 2024 highlighted the need for social, psychosocial, and spiritual support through activities, yet the facility did not meet these requirements, leaving residents without adequate opportunities for engagement and enrichment.
Disruptive Dining Environment Due to Resident Behavior
Penalty
Summary
The facility failed to provide a homelike dining environment for its residents, as observed during three meal observations in the common dining area. During these observations, a resident with a history of non-traumatic brain dysfunction and Alzheimer's disease was noted to be yelling profanities and making loud noises throughout the meals. This behavior was disruptive to other residents, as evidenced by interviews with two other residents who expressed discomfort and a desire to sit elsewhere. One resident, with moderate cognitive impairment, described the dining experience as unpleasant, while another resident with intact cognition expressed frustration at having to leave her friend due to the disruptive behavior. The facility's administrator and corporate nurse acknowledged the behavior of the disruptive resident but did not express concern, with the administrator stating that many residents cannot eat in their rooms and that others are used to the behavior. The corporate nurse mentioned that the team is discussing options to address the issue. The facility's policy on person-centered dining emphasizes the importance of a cheerful, inviting, and friendly dining atmosphere, which was not upheld in this situation.
Deficiencies in Meal Preparation and Menu Posting
Penalty
Summary
The facility failed to prepare and serve appropriate portions for residents on pureed and mechanical soft diets. Observations revealed that Staff F did not prepare enough food, resulting in insufficient portions of ham loaf and tater tots for residents. The dietary conversion chart used by Staff F lacked a column for nine servings, leading to incorrect portion sizes. Additionally, Staff F was unaware of the meaning of 'SH' on the dietary conversion chart, further contributing to the portioning errors. The facility's policy on portion control, which mandates that individuals receive appropriate portions as outlined on the menu, was not adhered to. Furthermore, the facility did not provide residents with menu options or alternatives, nor were menus posted in advance. Residents reported not knowing what meals would be served and expressed a lack of choice in their meals. The Administrator acknowledged that menus were only posted on a whiteboard before each meal and that no full menu or alternative options were provided in writing. The facility's policies on displaying menus and person-centered dining, which emphasize individualized nutrition care and the posting of planned menus, were not followed.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain food at safe and appetizing temperatures during meal service, as observed by surveyors. On June 5, 2024, at 11:15 AM, a cook, identified as Staff F, recorded the temperature of the lunch menu items, noting the Ham Loaf at 139.5°F and the lettuce at 40.8°F. However, during food service, the lettuce was served at room temperature from a serving bowl on the counter. Later, at 1:20 PM, Staff F recorded the Ham Loaf temperature at 129.5°F, which was below the facility's policy requirement for hot foods to remain above 135°F. The facility's policy, dated 2021, mandates that hot foods should stay above 135°F and cold foods below 41°F during the holding and plating process until the food leaves the service area. On June 7, 2024, the Administrator confirmed that staff should adhere to the facility's policy regarding food service temperatures. The failure to maintain these temperatures as per the policy was identified as a deficiency during the survey.
Sanitary Practices Deficiency in Food Preparation
Penalty
Summary
The facility failed to maintain sanitary practices in the food preparation area, as observed during a survey. Staff F was seen with an uncovered mustache and goatee, and his head cap did not contain all of his hair. Additionally, Staff F handled food with bare hands, slicing tomatoes and placing them in serving dishes without gloves. He also retrieved a serving scoop from a drawer and placed it face-down on a counter used for food preparation. Furthermore, Staff F filled a dressing dispenser, allowing the nozzle tip to touch his ungloved palm, and handled lettuce with bare hands, placing it back into a bowl after touching a resident's plate. He also used bare hands to place buttered bread in a skillet, reached into a bag of cheddar cheese, and cut a cooked sandwich on a plate. The facility's policy on General Food Preparation and Handling, dated 2021, indicated that bare hands should never touch ready-to-eat raw food directly, and disposable gloves should be used and discarded after each use. Employees are required to wash hands before putting on gloves and after removing them. The policy also directed staff to use tongs or other serving utensils to serve bread or other items to avoid bare hand contact with food. The Administrator confirmed that Staff F should have been wearing beard and hair nets and that gloves should be worn for all meal preparation.
Failure to Timely Notify Emergency Contact of Resident Evacuation
Penalty
Summary
The facility failed to provide timely notification to the emergency contact of a resident who was evacuated and transferred to another facility. The incident involved Resident #94, who had a planned discharge assessment with an anticipated return. On the morning of the incident, an emergency evacuation was initiated at approximately 4:30 AM, and the resident was transferred to another facility by 9:10 AM. However, the resident's emergency contact was not notified of the evacuation and transfer until approximately 2:50 PM. Hospice staff assisting with the relocation expressed frustration over the lack of communication to the resident's emergency contact. The facility's administrator acknowledged the expectation for timely notification, but no policy was provided.
Failure to Complete Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to complete discharge summaries for two residents, leading to a deficiency in the communication of necessary information at the time of discharge. Resident #43, who was admitted for skilled services, had a BIMS score indicating moderately impaired cognition and required supervision for bathing. Despite being managed by the PACE program, the facility did not provide a discharge summary, as confirmed by the Director of Nursing. The discharge documentation was stored in a separate system by PACE, and the facility acknowledged the failure to meet the discharge summary requirement. Similarly, Resident #94, who was transferred to another facility for an emergency evacuation, did not have a completed discharge summary. The record lacked a recapitulation of the resident's stay, and the Corporate Nurse confirmed the absence of the discharge summary. The responsibility for this oversight was attributed to a former staff member, and the facility recognized that the discharge summary should have been completed.
Failure to Include Resident and Family in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that quarterly interdisciplinary team meetings included the resident and/or their representative to discuss changing goals and review or revise the care plan for one resident. This deficiency was identified during a review of records, interviews with the responsible party, and staff interviews. The resident in question had a moderately impaired cognitive status, as indicated by a score of 9 out of 15 on the Brief Interview for Mental Status (BIMS) exam. The resident had diagnoses including non-traumatic brain dysfunction, dementia, renal diseases, depression, and chronic pain. The care plan, initiated earlier in the year, included interventions to keep the resident and family informed about health conditions and to encourage family involvement. During an interview, the responsible party for the resident stated they had never been informed about the option to participate in care plan meetings, nor had they received any invitations to such meetings. The responsible party expressed a desire to be involved in the care planning process. Additionally, the MDS Coordinator, who was new to the facility, reported being unable to locate any past documentation on care plan conferences and acknowledged the absence of a systematic process for including residents and families in quarterly care conferences. The facility did not have a policy regarding these conferences and claimed to follow regulatory processes.
Medication Administration Deficiency
Penalty
Summary
The facility failed to adhere to professional standards during medication administration for a resident with multiple diagnoses, including heart disease, diabetes, and respiratory failure. During an observation, a Certified Medication Aide (CMA) attempted to administer Thiamine to the resident but used a 100 mg pill from a stock bottle instead of the prescribed 50 mg dose. The CMA recognized the error after being prompted by a surveyor and returned the incorrect pill to the stock bottle, which is against the facility's medication administration policy. Additionally, the resident was given a fast-acting insulin injection by an LPN, but the meal was not served promptly, leaving the resident waiting for food. Furthermore, the CMA failed to instruct the resident to rinse their mouth after using the Trelegy inhaler, as required by the medication administration record (MAR) and manufacturer instructions. These actions demonstrate a lack of adherence to professional standards and facility policies, as confirmed by the Director of Nurses (DON) during an interview.
Inadequate Catheter Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care to minimize or prevent complications from urinary tract infections for a resident with a suprapubic catheter. The resident, who had a history of seizure disorders, cerebral infarction, intellectual disability, renal disease, and neurogenic bladder, required maximum assistance for personal hygiene and dressing. Observations revealed that the resident's catheter bag was improperly managed, as it was seen on the floor and dragging under the wheelchair, which poses a risk for infection. Interviews with staff and the Director of Nursing confirmed that the catheter bag should not be on the floor, acknowledging the associated risks of urinary tract infections. The facility lacked a specific policy addressing the management of urinary catheter bags, although they had a general catheter care policy aimed at preventing infection. The resident's responsible party was notified of a recent urinary tract infection, for which the resident was being treated with antibiotics.
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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