Accura Healthcare Of South Des Moines
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Iowa.
- Location
- 4911 Sw 19th Street, Des Moines, Iowa 50315
- CMS Provider Number
- 165273
- Inspections on file
- 35
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Accura Healthcare Of South Des Moines during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple psychiatric diagnoses suffered a nasal fracture and was instructed to follow up with ENT, but the facility failed to document the ENT referral and related communications in the EHR. The DON later acknowledged the omission and entered a late progress note after the deficiency was identified.
A resident with dementia and anxiety was involved in multiple incidents of physical aggression towards other residents, including scratching and hitting. The facility's care plan lacked specific interventions to prevent these altercations, and staff reported difficulty in managing the resident's behavior. Despite attempts to separate residents and implement checks, the facility failed to protect residents from abuse.
The facility did not maintain hot holding temperatures above 135°F for meals served to residents. Food was placed in warming carts and transported to the CCDI unit, but upon distribution, the test tray showed mixed vegetables at 115°F and tuna casserole at 128°F, both below the required temperature. The facility's policy requires food to be delivered at temperatures above 135°F.
A facility failed to implement effective interventions to prevent resident-to-resident altercations, particularly involving a resident with a history of aggression. Despite existing policies, the care plan lacked specific strategies to manage the resident's behavior, leading to multiple incidents of physical aggression. Staff expressed uncertainty about handling the resident's unpredictable behavior, and the MDS Coordinator did not include details of aggression in care plans.
A resident with breast cancer and a history of ovarian cancer did not complete genetic testing due to the facility's failure to follow physician's orders. The facility canceled the first appointment due to transportation issues and missed the second appointment because the resident did not want to rush and felt unwell. There was no documentation or rescheduling of the appointment, and the facility lacked a specific policy for handling physician's orders.
The facility failed to uphold residents' dignity as staff were observed using personal cell phones during work hours, neglecting their duties. A CMA and a CNA were seen on their phones during meal times, leaving residents unattended. Interviews revealed that staff phone use in residents' rooms made them feel ignored and uncomfortable, with some staff speaking non-English languages, adding to the discomfort. The DON confirmed the expectation for staff to refrain from phone use unless on break, aligning with the facility's policy against phone use during work.
The facility failed to maintain a clean and homelike environment, with issues such as a wooden pallet with flooring boxes in a common area, damaged baseboard heaters, missing baseboards, and garbage left in a resident's room. A resident's bed had a loose headboard, and a divider curtain was stained. Staff interviews revealed delays in addressing maintenance and housekeeping issues, and the facility lacked a policy for a homelike environment.
The facility failed to supervise and provide necessary care for residents in the CCDI unit, as family members reported neglect, including residents being found soiled with dried feces. A CNA was observed asleep during a resident's behavioral episode and initially denied a resident's request for a beverage. The DON confirmed that sleeping on the job violated the facility's code of conduct.
The facility failed to follow infection control protocols for residents requiring catheter and wound care. A resident with a suprapubic catheter did not receive care with enhanced barrier precautions, and there was no soap available for hand hygiene. Another resident with a pressure ulcer had dressing changes without proper glove changes or equipment cleaning. Additionally, nebulizer equipment was not rinsed after use, and a resident with an indwelling catheter was transferred without proper hand hygiene. These deficiencies were confirmed by staff interviews.
A resident with dementia and other disorders reported thumb pain for two weeks before receiving an X-ray. Despite family concerns and staff awareness, the facility failed to document or report the pain adequately, and Tylenol was only documented as given once. The DON expected staff to document and report pain, but the facility lacked a policy for assessment and intervention.
The facility failed to use a safe transfer technique with a mechanical lift for a resident with severe cognitive impairment, did not maintain adequate ventilation in a server room, and lacked accessible bathroom call lights for residents. The mechanical lift was improperly used, the server room was excessively warm due to a malfunctioning AC, and a bathroom call light was inaccessible, leaving a resident unable to request assistance.
A resident with dementia and severe cognitive impairment did not receive complete incontinence care as per facility policy. A CNA failed to follow proper peri-care procedures, including not changing gloves or sanitizing hands when moving from dirty to clean areas. The DON confirmed the expectation for staff to adhere to the peri-care policy.
A facility failed to maintain a medication error rate below 5%, with an LPN administering a cocktail of crushed medications through a PEG tube without individual administration or proper flushing, contrary to policy. The resident had no specific order for cocktailing medications, and the facility's policy required separate administration unless otherwise ordered.
A resident with a PEG tube was administered medications through the tube instead of orally, contrary to physician's orders. The facility's policy required separate administration of medications unless ordered otherwise, which was not followed. The DON confirmed the absence of an order to cocktail medications, and staff interviews highlighted the expectation for individual administration with water flushes.
The facility failed to notify two residents of the bed hold policy during hospital transfers. Both residents, with no cognitive impairment, were transferred and returned without documentation of notification. Interviews confirmed the absence of completed bed hold forms, despite the expectation for such documentation.
A facility failed to include necessary medications in a resident's Baseline Care Plan. The resident, with heart failure, anxiety, and mood disorders, was prescribed Apixaban, Duloxetine, and Risperdal, but these were not documented in the care plan. The DON acknowledged the expectation for inclusion, and the Administrator noted the lack of a facility policy for the Baseline Care Plan.
A resident with a history of aggressive behavior slapped another resident in the face in a common area, despite known interventions to prevent such incidents. The resident was in a wheelchair without the required alarm, and no staff were present to intervene. The facility failed to implement and evaluate the effectiveness of interventions to prevent harm, leading to a breach in resident safety and abuse prevention protocols.
The facility failed to implement adequate safety interventions for a resident with severe cognitive deficits, leading to incidents of abuse towards other residents. Despite having a care plan, the resident was left unsupervised, resulting in close proximity to female residents without staff intervention. Additionally, the facility did not effectively prevent falls for another resident, who experienced multiple falls, including one resulting in a hip fracture. The lack of a fall prevention policy and inconsistent staff adherence to care plans contributed to these deficiencies.
An incident of unwanted sexual touching between two residents led to immediate actions by the facility. A resident with a known history of inappropriate sexual behavior was later observed unsupervised with another vulnerable resident. The facility's failure to provide adequate supervision and a safe environment contributed to the risk of unwanted sexual advances, impacting residents' well-being.
A resident with multiple diagnoses had their medication, Tramadol, administered despite physician's orders to hold it 48 hours before a scheduled CT Myelogram. This error led to the rescheduling of the resident's appointment. The incident was confirmed by the Director of Nursing and reported by a Certified Medication Aide who mistakenly gave the medication.
The facility failed to provide two baths a week for two residents due to staffing issues. One resident did not receive baths for a week because the shower aide was on vacation, while another resident missed baths over a ten-day period. Both residents require assistance with bathing, and the Director of Nursing confirmed the lapses.
A resident with multiple diagnoses, including hypertension and psychotic disorder, was not seen by a primary care physician for over four months. The clinical record lacked documentation of required physician visits, which was confirmed by the Regional Clinical Nurse Specialist.
The facility staff failed to answer call lights within the expected 15 minutes for a resident with hypertension, anxiety, depression, and psychotic disorder. The resident reported delays of over half an hour, and multiple CNAs confirmed the issue. The administrator verified that the expectation is to respond within 15 minutes, as per regulations.
Failure to Document ENT Referral and Communication
Penalty
Summary
The facility failed to maintain complete and accurate documentation regarding an ENT referral for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including Alzheimer's Disease, dementia, and behavioral issues. After the resident experienced a fall resulting in a nasal fracture, emergency department discharge instructions specified that the resident should be re-evaluated by ENT within the following week. However, a review of the resident's electronic health record (EHR) did not show any documentation of communication or referral to ENT as instructed. Interviews with the DON revealed that calls were made to the ENT clinic regarding the referral, and follow-up communication occurred, but these actions were not documented in the resident's EHR at the time. The DON acknowledged the lack of documentation for both the ENT referral and communication with the resident's family. A late entry progress note was later created to reflect the communication, but this was after the deficiency was identified.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically in cases involving resident-to-resident altercations. Resident #4, who has a history of non-Alzheimer's dementia, anxiety, and depression, was involved in multiple incidents of physical aggression towards other residents. These incidents included scratching, hitting with a plastic bottle, and kicking other residents. The facility's care plan for Resident #4 lacked specific interventions to prevent these altercations, despite the resident's known history of aggressive behavior. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents involving Resident #4. Staff interviews revealed that they were aware of Resident #4's aggressive tendencies but were unable to consistently prevent altercations. The care plan for Resident #4 included general strategies for managing mood and behavior but did not address the specific issue of physical aggression towards other residents. Staff members reported difficulty in managing Resident #4's behavior, noting that the resident could become aggressive without provocation. Despite attempts to separate residents and implement 15-minute checks, the facility did not have a concrete plan to prevent future incidents. The lack of effective interventions and documentation in the care plan contributed to the facility's failure to protect residents from abuse.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to maintain hot holding temperatures above 135 degrees Fahrenheit for meals served to residents. On the observed date, the Dietary Services Manager placed plated food into warming carts, which were then transported to the Chronic Confusion Dementing Illness (CCDI) unit. Upon arrival, staff began distributing the trays to residents. However, when the State Agency (SA) checked the temperatures of the test tray, the mixed vegetables were at 115 degrees Fahrenheit and the tuna casserole at 128 degrees Fahrenheit, both below the required temperature. The facility's policy, dated 2021, mandates that foods be transported and delivered at temperatures above 135 degrees Fahrenheit. The Dietary Services Manager later stated that she expected hot foods to be held above 140 degrees Fahrenheit.
Failure to Implement Effective Interventions for Resident Aggression
Penalty
Summary
The facility failed to implement resident-centered care plan interventions to protect residents from physical abuse, specifically in cases of resident-to-resident altercations. The report highlights incidents involving Resident #4, who has a history of verbal and physical aggression towards other residents. Despite the facility's policy on abuse prevention and the requirement for comprehensive care plans, the care plan for Resident #4 lacked specific interventions to prevent future altercations. The facility continued to use interventions such as resident separation and 15-minute checks, but these measures were insufficient in preventing further incidents. Resident #4, diagnosed with non-Alzheimer's dementia, anxiety, and depression, exhibited aggressive behaviors towards other residents on multiple occasions. The incidents included scratching Resident #13, hitting Resident #5 with a plastic bottle, striking Resident #6, and physically assaulting Resident #11. The care plan for Resident #4 did not document the history of these altercations or provide clear guidance for staff on preventing future incidents. Staff interviews revealed a lack of concrete interventions and uncertainty about handling Resident #4's aggressive behavior. Staff members, including a Certified Medication Aide, LPNs, and the interim DON, acknowledged the challenges in managing Resident #4's behavior. They reported that Resident #4's aggression was often unprovoked and difficult to predict, making it challenging to prevent altercations. The facility's efforts to intervene were described as inadequate, with staff expressing uncertainty about effective strategies to manage the resident's behavior. The MDS Coordinator admitted to not including specifics about physical aggression in care plans, further highlighting the deficiency in addressing the resident's needs and ensuring the safety of other residents.
Failure to Follow Physician's Orders for Genetic Testing Referral
Penalty
Summary
The facility failed to follow a physician's order for a genetic testing referral for a resident diagnosed with breast cancer, who also had a history of ovarian cancer and an extensive family history of cancer. The resident, who had intact cognition as indicated by a BIMS score of 15 out of 15, was scheduled for genetic testing on two occasions. The first appointment was canceled by the facility due to a lack of transportation, and the second appointment was missed because the resident did not want to rush and was not feeling well. There was no documentation of these events or any rescheduling of the appointment. Staff interviews revealed a lack of communication and documentation regarding the resident's appointments. The Staffing Coordinator did not see the initial appointment on the calendar and assumed another driver would take the resident to the second appointment. When this did not happen, the resident declined to rush to the appointment. The Driver mentioned that appointments were sometimes rescheduled if the nurse forgot to note them. The interim DON acknowledged that the facility should follow physician's orders, including referrals, but the Administrator admitted there was no specific policy for physician's orders, relying instead on standards of practice.
Staff Cell Phone Use Disrupts Resident Care and Dignity
Penalty
Summary
The facility failed to respect residents' dignity and self-determination by allowing staff to use personal cell phones during work hours, which distracted them from providing proper care. Observations revealed that a Certified Medication Aide (CMA) and a Certified Nurse Aide (CNA) were frequently on their phones during meal times and while assisting residents, neglecting their duties and failing to attend to residents' needs promptly. This behavior was noted in the dining room, where staff were observed using their phones instead of engaging with residents, leading to situations where residents were left unattended or had to be assisted by other staff members. Interviews with residents and family members corroborated these observations, with reports of staff being on their phones even while in residents' rooms, which made residents feel ignored and uncomfortable. Additionally, some staff members were reported to speak in languages other than English in front of residents, further contributing to feelings of discomfort and disrespect. The Director of Nursing (DON) acknowledged the issue, stating that staff were expected to refrain from using phones unless on break, and no exceptions to this policy were known. The facility's cell phone usage policy also emphasized that personal phone use during work negatively impacts resident care.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as observed during a survey. Several deficiencies were noted, including a wooden pallet with boxes of flooring left in a common area, bent and torn metal flaps on baseboard heaters, and missing baseboards in hallways. Additionally, a clear plastic bag of garbage containing a soiled brief and other waste was found on the floor in a resident's room, along with soiled washcloths. A divider curtain in another room had a dried brown stain, and a resident's bed had a loose and slanted headboard with rough wood and black ties holding it together. The bathroom light in one room was not functioning. Interviews with staff revealed that maintenance and housekeeping issues were reported but not always addressed promptly. The Maintenance Assistant mentioned that repairs were reported through a work order system or verbally, and the Regional Maintenance Director noted ongoing renovations. However, some issues, like the broken headboard, had persisted for a while. The housekeeping staff reported cleaning divider curtains when they appeared dirty, but the stained curtain remained unchanged during the survey period. The facility administrator acknowledged the challenges in completing renovations and confirmed the absence of a policy for maintaining a homelike environment.
Neglect and Inadequate Supervision in CCDI Unit
Penalty
Summary
The facility failed to appropriately supervise and provide necessary interventions for residents in the Chronic Confusion and Dementing Illnesses (CCDI) unit, as evidenced by direct observations and interviews. Family members reported that they had to take over care duties due to neglect by the facility staff, with instances of residents being found heavily soiled with dried feces. Staff reportedly claimed that residents refused care, leading to prolonged periods without showers. These reports indicate a pattern of neglect in attending to the residents' basic hygiene needs. During a direct observation, a Certified Nurses Aide (CNA), identified as Staff N, was found asleep in a chair in the CCDI unit while a resident was having a behavioral episode. Despite attempts by another staff member, Staff O, to wake her, Staff N continued to sleep until directly addressed. Additionally, Staff N was observed denying a resident's request for a beverage, only relenting after persistent requests. The Director of Nursing confirmed that sleeping on the job was against the facility's code of conduct, as outlined in their work rules.
Infection Control Deficiencies in Catheter and Wound Care
Penalty
Summary
The facility failed to implement proper infection control techniques for residents requiring catheter care, treatments, and dressing changes. Resident #6, who had a suprapubic catheter and a history of urinary tract infections, was observed during catheter care without the use of enhanced barrier precautions. Staff C, a certified nursing assistant, did not don an isolation gown, failed to use a barrier for the graduate container, and did not cleanse the catheter port with alcohol after emptying it. Additionally, there was no soap available in the resident's room for proper hand hygiene, and the soap dispenser was found to be non-functional. Resident #28, diagnosed with diabetes and a stage 3 pressure ulcer, was observed during a dressing change where infection control protocols were not followed. Staff A, an LPN, used scissors from her uniform pocket without cleaning them, and handled supplies without changing gloves or sanitizing hands between tasks. The supplies were carried against her uniform, which is against infection control practices. The Infection Preventionist confirmed that Resident #28 was on enhanced barrier precautions, which were not adhered to during the procedure. The facility also failed to properly clean nebulizer equipment after use for Resident #17, as the nebulizer chamber and mask were not rinsed with water post-treatment. Additionally, Resident #41, who had an indwelling catheter, was transferred using a mechanical lift without proper hand hygiene between tasks, and the lift was not cleaned after use. These observations indicate a lack of adherence to infection control protocols, as confirmed by interviews with staff and the Director of Nursing.
Failure to Provide Timely Assessment and Intervention for Resident Pain
Penalty
Summary
The facility failed to provide appropriate assessment and timely intervention for a resident, identified as Resident #61, who reported pain in her right thumb. Despite the resident's family member communicating concerns about the pain to staff over a two-week period, the nursing staff did not contact the resident's physician promptly or provide adequate treatment. The resident, who has diagnoses of Non-Alzheimer's Dementia, anxiety disorder, and bipolar disorder, was dependent on staff for her emotional, intellectual, physical, and social needs. The care plan was last updated on 07/15/2024, but the staff did not adhere to the necessary protocols for managing the resident's reported pain. Interviews with staff members revealed that the resident had been complaining of thumb pain for approximately two weeks before an X-ray was ordered on 07/25/2024. Staff M, an RN, assessed the resident but did not find any impairment or swelling, and provided Tylenol as needed. However, the Medication Administration Record indicated that Tylenol was only documented as administered once between 07/01/2024 and 08/22/2024. Staff K, a CMA, and Staff L, a CNA, also acknowledged the resident's complaints but failed to document or report them adequately. The Director of Nursing stated that the expectation is for staff to document and report new pain complaints, but the facility lacked a policy for assessment and intervention, as confirmed by the facility administrator.
Deficiencies in Safe Transfer, Ventilation, and Call Light Accessibility
Penalty
Summary
The facility staff failed to utilize a safe transfer technique when using a mechanical lift for a resident with severe cognitive impairment and dependence on staff for transfers. The resident, diagnosed with dementia, muscle weakness, and anxiety, was observed being transferred by two CNAs using a mechanical lift. However, the CNAs did not follow the proper procedure as outlined in the facility's Hoyer Lift Competency and the manufacturer's user manual. Specifically, the mechanical lift legs were not kept open during the transfer, which is necessary to ensure the resident's safety and prevent the lift from tipping. Additionally, the facility failed to maintain adequate ventilation and temperature control in a room containing servers and electronic devices. Observations revealed that the server room was extremely warm, with the door propped open and fans used to circulate air. Interviews with staff indicated that the air conditioning unit in the server room was not functioning properly, and there were challenges in keeping the room cool due to outdated equipment and structural limitations. The temperature in the server room was recorded at 78 degrees Fahrenheit, and the air conditioning unit required resetting to function. Furthermore, the facility did not ensure that bathroom call lights were accessible for residents and staff in one of the units observed. A resident reported being left in a bathroom without a call light to request assistance. Observations confirmed that the bathroom had a call light fixture with a small metal lever but no string or device for activation, making it inaccessible for residents needing help.
Inadequate Incontinence Care for Resident with Dementia
Penalty
Summary
The facility staff failed to provide complete incontinence care for a resident with severe cognitive impairment and incontinence. The resident, diagnosed with dementia, had a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severely impaired cognition, and required maximum assistance for bed mobility and dressing. The care plan directed staff to clean the peri-area after each incontinence episode. However, during an observation, a certified nursing assistant (CNA) did not follow the facility's peri-care procedure. The CNA cleansed the resident's groin and peri-area but left soiled wipes in place before removing them, and did not change gloves or sanitize hands when moving from a dirty to a clean area. The Director of Nursing (DON) confirmed that staff are expected to follow the peri-care policy, which includes changing gloves and sanitizing hands when transitioning from dirty to clean areas. The facility's Peri Care Competency outlines specific steps for providing care, including using a new wipe for each area, removing gloves before turning the resident, and washing hands. The CNA's actions did not align with these procedural steps, leading to the deficiency in providing appropriate incontinence care for the resident.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by 5 errors out of 37 opportunities, resulting in a 13.51% error rate. During an observation, a Licensed Practical Nurse (LPN) prepared medications for a resident with a PEG tube by crushing pills and mixing them with liquid medications and warm water in a Styrofoam cup. The LPN then administered the mixture through the PEG tube without measuring the water used for flushing and without individual administration of each medication, contrary to the facility's policy. The resident involved was on a mechanical soft diet and had an active verbal order allowing medications to be given through the PEG tube as needed. However, there was no specific order permitting the cocktailing of medications. Interviews with the Director of Nursing (DON) and another LPN confirmed that the facility's policy required medications to be administered separately unless a physician's written order allowed them to be combined. The policy also specified that the enteral tube should be flushed with at least 15 ml of water after each medication, which was not followed in this instance.
Medication Administration Error via PEG Tube
Penalty
Summary
The facility failed to administer medications as per the physician's orders for a resident with a history of stroke, non-Alzheimer's dementia, seizure disorder, and dysphagia. The resident, who had impaired memory and decision-making skills, was observed receiving medications through a gastrostomy tube instead of orally as ordered. The care plan indicated the resident had a PEG tube placed during hospitalization, and the medication administration record showed that medications were given through the tube without a specific order to do so. The facility's policy required medications to be administered separately unless there was a physician's written order to combine them, which was not present in this case. During the observation, an LPN crushed and mixed several medications in a Styrofoam cup with hot water and administered them through the resident's PEG tube. Interviews with the Director of Nursing and other staff confirmed that the medications should have been given individually with water flushes, as per the facility's policy. The Director of Nursing acknowledged the lack of an order to cocktail the medications. Additionally, a family member and a speech therapist provided insights into the resident's condition and the decision to keep the PEG tube in place, although the resident was able to eat with encouragement.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to residents or their representatives at the time of transfer to a hospital for two out of three residents reviewed. Resident #36, who had diagnoses of heart failure and diabetes, was admitted to the hospital and returned to the facility without documentation of bed hold policy notification. Similarly, Resident #43, with diagnoses of diabetes and cancer, was also transferred to the hospital and returned without such notification. Both residents had a Brief Interview for Mental Status score indicating no cognitive impairment for decision-making. Interviews with the facility's Administrator and Director of Nursing confirmed that no bed hold forms were completed for these residents, despite the expectation that a bed hold should be completed with any hospital transfer. The facility reported a census of 71 residents at the time of the survey.
Failure to Include Medications in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a Baseline Care Plan that included necessary medications and monitoring for a resident. The resident, who had diagnoses of heart failure, anxiety disorder, and mood disorder, was prescribed Apixaban (an anticoagulant), Duloxetine (an antidepressant), and Risperdal (an antipsychotic). However, the Baseline Care Plan did not document these medications. This omission was identified during a clinical record review and staff interviews. The Director of Nursing acknowledged the expectation for these medications to be included in the care plan, and the Administrator confirmed the absence of a facility policy for the Baseline Care Plan, stating that the facility is expected to follow regulations.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically in the case of Resident #2, who had a known history of aggressive behaviors, including physical and sexual abuse towards other residents and staff. Despite these known behaviors, the facility did not effectively implement or evaluate interventions to prevent harm. On the day of the incident, Resident #2, who was in a wheelchair without the required alarm, self-propelled towards Resident #3 and slapped her in the face. This occurred in the lounge area where no staff were present to intervene in time. Resident #2's Minimum Data Set (MDS) assessment indicated severe cognitive deficits and documented a history of physical and behavioral symptoms, including wandering and aggression. The care plan for Resident #2 included interventions such as the use of a silent alarm in his chair, frequent visual checks, and ensuring he was not left in his wheelchair unsupervised. However, these interventions were not effectively implemented, as evidenced by the absence of the alarm and lack of staff presence during the incident. Interviews with staff revealed that they were aware of Resident #2's behavioral issues and the interventions required, yet these were not consistently followed. Staff reported that Resident #2 was supposed to be monitored closely and not allowed near female residents, but on the day of the incident, these protocols were not adhered to. The facility's failure to enforce these measures resulted in Resident #2 being able to approach and physically harm Resident #3, highlighting a significant lapse in resident safety and abuse prevention protocols.
Inadequate Supervision and Safety Interventions in LTC Facility
Penalty
Summary
The facility failed to implement adequate safety interventions to prevent further abuse by a resident with severe cognitive deficits, identified as Resident #2. This resident had a history of physical and sexual abusive behaviors towards staff and other residents. Despite having a care plan that included the use of alarms and frequent visual checks, observations revealed that Resident #2 was left unsupervised in common areas, leading to incidents where he was in close proximity to female residents, including Resident #3, without staff intervention. Interviews with staff confirmed that they were aware of the interventions but failed to consistently apply them, resulting in a lack of protection for other residents. Additionally, the facility did not effectively prevent falls for Resident #6, who had severe cognitive impairments and required assistance for transfers and ambulation. Despite being identified as a fall risk, the resident experienced multiple falls, including one that resulted in a head injury and a subsequent hip fracture. The investigation into the fall incidents revealed that staff did not maintain appropriate physical contact or supervision, as required by the care plan, and there was confusion among staff regarding the level of assistance needed. The facility lacked a fall prevention policy, contributing to the inadequate management of the resident's fall risk. The report highlights the facility's failure to update care plans and implement necessary interventions following incidents of abuse and falls. The lack of staff presence and supervision in common areas, combined with insufficient adherence to care plans, resulted in repeated safety hazards for residents. The absence of a comprehensive fall prevention policy further exacerbated the risk of injury for residents with cognitive impairments.
Inadequate Supervision Leading to Resident Safety Concerns
Penalty
Summary
The report details a concerning incident of sexual abuse involving Resident #1 and Resident #2 in a long-term care facility. Resident #1 reported unwanted sexual touching by Resident #2 on 3/16/24, leading to immediate actions being taken by the facility. Resident #2, known for sexual behavior and comments, was observed unsupervised with Resident #4, a vulnerable resident with poor cognitive status, on 4/23/24. The facility failed to provide a safe environment, putting residents at risk for unwanted sexual advances. Resident #2's history of inappropriate sexual behaviors and comments towards others, as well as the lack of proper supervision, contributed to the deficiency in protecting residents from sexual abuse. The facility's failure to adequately supervise Resident #2, despite being aware of his history of sexual behavior, highlights a critical lapse in ensuring resident safety. Resident #1's fear and reluctance to leave her room following the incident further underscore the impact of the deficiency on residents' well-being. The facility's policies and interventions, such as the installation of motion alarms and staff education, indicate a reactive approach to addressing the deficiency rather than a proactive one that could have potentially prevented the abuse from occurring.
Failure to Hold Medication as Directed by Physician
Penalty
Summary
The facility failed to hold a medication as directed per the physician's orders, which caused a resident to reschedule an appointment. Resident #1, who has diagnoses including hypertension, anxiety, depression, and psychotic disorder, was supposed to have Tramadol held 48 hours prior to a scheduled CT Myelogram. Despite the physician's orders and documentation in the Medication Administration Record (MAR) and Progress Notes, the medication was administered on multiple occasions within the 48-hour window before the appointment, leading to the need for rescheduling the procedure. The resident's Annual Minimum Data Set (MDS) indicated no impairments with decision-making or memory problems, and the resident required partial to moderate assistance with personal hygiene. The After Visit Summary and Progress Notes clearly documented the need to hold Tramadol, but this directive was not followed by the staff, resulting in the medication being given on 4/2/24 and 4/3/24, and the morning of 4/4/24, contrary to the physician's orders. The error was reported by a Certified Medication Aide (CMA) who mistakenly administered the medication, and the incident was confirmed by the Director of Nursing during an interview on 4/25/24. The failure to follow the physician's orders led to the resident's appointment being rescheduled to May 2nd, with the same instructions to hold Tramadol 48 hours prior to the new appointment date.
Failure to Provide Required Baths Due to Staffing Issues
Penalty
Summary
The facility failed to provide two baths a week as directed for two residents. Resident #1, who has diagnoses including hypertension, anxiety, depression, and psychotic disorder, did not receive baths between April 8, 2024, and April 15, 2024. The resident, who has no impairments with decision-making or memory problems, reported that the baths were missed because the shower aide was on vacation and there was not enough staff to cover. This was confirmed by the resident during an interview on April 23, 2024. Resident #4, who has diagnoses including hypertension, cerebrovascular accident, non-Alzheimer's dementia, hemiplegia, and depression, did not receive baths between April 3, 2024, and April 13, 2024. The resident has short and long-term memory impairments and requires substantial to maximal assistance with bathing. A CNA confirmed that the baths were not completed due to insufficient staffing. The Director of Nursing acknowledged that the baths were not completed as required for both residents and stated that the expectation is for staff to complete baths twice a week.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least once every 60 days. Resident #1, who had diagnoses including hypertension, anxiety, depression, and psychotic disorder, was not seen by the primary care physician between October 26, 2023, and March 11, 2024. The resident's Minimum Data Set (MDS) indicated no impairments in decision-making or memory, and the resident required partial to moderate assistance with personal hygiene. The clinical record showed a behavioral health visit on October 26, 2023, and a physician assistant visit on March 11, 2024, but lacked documentation of any primary care physician visits during the intervening period. This deficiency was confirmed by the Regional Clinical Nurse Specialist during an interview on April 25, 2024.
Delayed Response to Call Lights
Penalty
Summary
The facility staff failed to answer resident call lights in a timely manner, specifically within the expected 15 minutes, for one of the three residents reviewed. Resident #1, who has diagnoses including hypertension, anxiety, depression, and psychotic disorder, reported that it could take staff over half an hour to respond to call lights. This resident has no impairments with decision-making or memory, as indicated by a BIMS score of 13, and requires partial to moderate assistance with personal hygiene and bathing. Multiple staff members, including three CNAs, confirmed that it often takes over 15 minutes to answer call lights. The facility's administrator also verified that the expectation is to respond to call lights within 15 minutes, as per state and federal regulations.
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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