Accura Healthcare Of Stanton
Inspection history, citations, penalties and survey trends for this long-term care facility in Stanton, Iowa.
- Location
- 213 Halland Avenue, Stanton, Iowa 51573
- CMS Provider Number
- 165332
- Inspections on file
- 18
- Latest survey
- October 7, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Accura Healthcare Of Stanton during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and a history of elopement risk, despite wearing a wander guard and having a care plan with specific interventions, was able to leave an outdoor group activity unsupervised. Staff interviews confirmed that no CNA was assigned to supervise residents with wander guards during the event, and the resident was not noticed missing until alerted by another resident. The resident was found at a nearby family home and returned without injury, highlighting a lapse in required supervision.
A resident with an initial negative Level I PASRR screening was later diagnosed with anorexia and unspecified psychosis, but the facility did not update or resubmit the PASRR referral as required. The DON, responsible for PASRR submissions, acknowledged the oversight and the lack of a formal policy contributed to the failure to refer the resident for a Level II PASRR evaluation.
A resident with a history of multiple medical conditions experienced several days of nausea and vomiting without documented vital signs or bowel assessments, despite ongoing symptoms and a care plan requiring such monitoring. Staff did not consistently assess or document the resident's condition, and there was no clear policy guiding response to changes in status. The resident was eventually hospitalized with a bowel obstruction and septic shock, and later died after returning to the facility.
A resident with multiple cardiac and respiratory diagnoses, who was ordered continuous oxygen therapy, was observed on two occasions with an empty oxygen tank while in the dining room. Staff interviews revealed that the LPN did not check the oxygen tank before transport and that staff relied on CNAs to report empty tanks. The DON confirmed that tanks could empty quickly at the prescribed flow rate and acknowledged that staff should have monitored them more closely. The facility lacked a policy and documentation of staff education on oxygen therapy standards.
The facility failed to personalize care plans for several residents, leading to deficiencies in meeting their needs. A resident's care plan for anticoagulant therapy lacked details on medication reasons and side effects, while another's antipsychotic medication plan was missing key information. A hospice care plan was not individualized, and other residents' plans lacked targeted interventions for cognitive and mood disorders. The MDS Coordinator was still learning the process, and the facility lacked specific policies for care plan updates.
The facility failed to employ a certified dietary manager, as the Dietary Manager had not purchased the necessary license despite passing the certification test. The facility's policy required sufficient and competent staffing, but the Administrator confirmed the DM lacked the correct certification.
The facility failed to properly prepare pureed diets for two residents and did not serve appropriate portions for others. Observations showed that the cook did not measure ingredients or final volumes, leading to improper preparation of pureed diets. Additionally, incorrect portion sizes were served for regular and carbohydrate-controlled diets, as the first 11 plates had partially full servings, contrary to menu specifications.
The facility failed to maintain sanitary practices in food storage and handling, with observations of unlabeled and undated food items, improper hand hygiene, and unsanitary kitchen conditions. Staff did not follow facility policies on food safety, leading to potential cross-contamination.
The facility failed to implement its Infection Prevention and Control Program, with staff not discarding PPE immediately and not performing hand hygiene. Additionally, the facility lacked a comprehensive water management plan to address Legionella risk, with the Maintenance Director unfamiliar with the water flow system and lacking necessary documentation.
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) within 2 days for two residents receiving skilled care under Medicare A. The Social Services Director was initially unaware of the NOMNC requirement, leading to residents not being informed about their right to appeal for continued Medicare coverage.
The facility did not ensure that two staff members completed the required Dependent Adult Abuse training within six months of hire. Despite attempts to locate the training certificates, documentation was not found, violating the facility's policy.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documented care needs. One resident's MDS inaccurately recorded cognitive status and medication use, while another's incorrectly noted bed rail use as a restraint. A third resident's MDS failed to document an unstageable pressure ulcer. The MDS Coordinator admitted to errors due to a lack of tracking systems and training, and the DON confirmed the absence of policies for MDS and care plan updates.
The facility failed to update care plans for two residents, one with a pressure ulcer and another with significant pain from a previous fall. Despite physician orders and ongoing treatment, the care plans were not revised to reflect these conditions. The MDS Coordinator was still learning the process, and the DON acknowledged the absence of a specific care plan policy.
A resident with functional limitations and dependency on staff for daily activities did not receive restorative activities to maintain range of motion, despite having a care plan and a Restorative Nursing Program. Staff were unaware of the program, and the resident had not been screened for therapy, leading to a deficiency in care.
The facility did not complete and post nurse staffing information at the beginning of each shift. A review on July 19, 2024, showed incomplete staffing data for the day and evening shifts, and all 17 staffing sheets for July 2024 were incomplete, with no sheet for July 17, 2024. The DON stated that the staffing sheet is initiated during the night shift, but there was no policy for posting staffing data.
A facility failed to serve food at safe temperatures, as observed when a cook prepared pureed pork ribs, carrots, and macaroni & cheese without checking their temperatures before placing them on the steam table. The food was later served to a resident with temperatures below the required 135 degrees Fahrenheit, contrary to the facility's policy.
A resident with moderately impaired cognition and multiple diagnoses, including Alzheimer's and COPD, sustained an injury of unknown origin and accused a staff member of causing a fall. The facility delayed reporting the incident to the State Agency, initially advised by corporate administration that it was not reportable. The reporting process began several days later, highlighting a deficiency in timely reporting.
A resident with moderate cognitive impairment and anxiety eloped from the facility due to inadequate supervision and security measures. Despite being identified as an elopement risk, the resident managed to remove his wander guard and exit the facility unnoticed, using a door code observed earlier. Staff were unaware of his absence until he returned with items from his home. Documentation of required checks was incomplete, and staff interviews revealed a lack of seriousness regarding the incident.
Two residents experienced inadequate pain management due to the facility's failure to utilize prescribed treatments and document pain assessments. One resident with a broken tailbone did not receive a lidocaine patch as ordered, and pain levels were not consistently recorded. Another resident under hospice care had pain medication administered late multiple times, despite reporting constant pain. The facility lacked a specific pain management policy, contributing to these deficiencies.
Failure to Provide Adequate Supervision for High Elopement Risk Resident During Outdoor Activity
Penalty
Summary
A deficiency occurred when a resident with a known high risk for elopement was not provided with adequate supervision during an outdoor group activity. The resident, who had a diagnosis of unspecified dementia and a BIMS score indicating moderate cognitive impairment, was assessed as a high elopement risk and wore a wander guard. Despite these precautions, the resident was able to leave the supervised activity area without staff noticing and walked to a nearby family home. The absence of direct supervision was confirmed by multiple staff interviews, with several staff members stating that no CNA was assigned to supervise residents with wander guards outside at the time of the incident. The resident's care plan included specific interventions for elopement risk, such as providing diversions, structured activities, and 1:1 supervision when outside, as well as the use of a wander guard. However, during the outdoor activity, staff were engaged in other tasks such as passing ice cream, providing entertainment, and assisting other residents, which led to a lapse in direct supervision. Staff interviews revealed confusion about who was responsible for supervising residents with wander guards, and it was acknowledged by the DON and other staff that there was a lack of clear assignment for supervision during the event. The resident was ultimately located by family and returned to the facility without injury. Documentation and interviews indicated that the facility's policy required supervision for residents at risk of elopement, but this was not consistently implemented during the incident. The DON and other staff confirmed that the expectation was for nursing staff to supervise residents with wander guards when outside, but this did not occur during the group activity. The deficiency was attributed to a breakdown in communication and assignment of supervision responsibilities, resulting in the resident's unsupervised exit from the facility.
Failure to Refer Resident for Level II PASRR Evaluation After New Mental Health Diagnoses
Penalty
Summary
A deficiency occurred when the facility failed to refer a resident for a Level II Preadmission Screening and Resident Review (PASRR) evaluation after the resident was identified with new or possible serious mental disorders. The resident initially had a negative Level I PASRR result, with the screening only documenting diagnoses of major depression and anxiety disorder. However, subsequent clinical record reviews revealed new diagnoses of anorexia and unspecified psychosis, which were not included in the original PASRR documentation. The facility did not update or resubmit the PASRR referral upon receiving these new diagnoses. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for PASRR submissions at the time and acknowledged that the new diagnosis of psychosis should have triggered a new PASRR referral. The DON admitted to not considering anorexia as a qualifying diagnosis for PASRR resubmission and recognized the oversight. Additionally, the facility lacked a formal policy for PASRR submissions and relied on general requirements for status changes, contributing to the failure to refer the resident for appropriate evaluation.
Failure to Assess and Intervene for Resident with Persistent Nausea and Vomiting
Penalty
Summary
The facility failed to provide adequate and timely assessment and intervention for a resident who experienced nausea and vomiting over a four-day period. Despite the resident's ongoing symptoms, including repeated vomiting and refusal of food and medications, the clinical record lacked documentation of vital signs or bowel assessments during this time. The care plan for the resident, who had a history of anemia, atrial fibrillation, heart failure, benign prostatic hyperplasia, and constipation, required staff to assess bowel sounds and abdomen and to report abnormalities to the primary care physician, as well as to follow bowel protocols and administer as-needed medication for constipation. Nursing progress notes indicated that the resident was seen by a doctor and treated for a suspected urinary tract infection, with antibiotics and anti-nausea medication prescribed. However, the resident continued to experience nausea, vomiting, and a decline in functional status, including increased lethargy and weakness. Staff interviews revealed that vital signs and bowel assessments were not consistently performed or documented, and staff were uncertain about the expectations for monitoring residents on antibiotics. The Director of Nursing confirmed that there was no policy on resident change in status and that standard of care was to be followed, but could not provide a specific resource for staff guidance. The resident was eventually sent to the emergency department after continued deterioration, where he was found to have a small bowel obstruction with perforation and septic shock. Hospital records documented hypotension, tachycardia, and significant abdominal findings. The resident was transferred for possible surgical intervention and later returned to the facility, where he subsequently passed away. The lack of timely assessment and intervention, including failure to monitor vital signs and bowel status, contributed to the deficiency identified by surveyors.
Failure to Ensure Supplemental Oxygen Provided as Ordered
Penalty
Summary
Staff failed to provide safe and appropriate respiratory care by not ensuring that a resident on continuous oxygen therapy received supplemental oxygen as ordered. The resident, who had diagnoses including atrial fibrillation, heart failure, renal insufficiency, diabetes mellitus, and a cardiac pacemaker, was observed on two separate occasions in the dining room with an oxygen tank that was empty, as indicated by the gauge needle in the red zone. The nasal cannula was attached to the resident but the tank was not supplying oxygen. The resident required minimal assistance with activities of daily living and had intact cognitive ability. Interviews with staff revealed that the LPN who assisted the resident to the dining room did not check the oxygen tank, and staff relied on CNAs to notify them if a tank was empty. The DON acknowledged that at the prescribed flow rate, tanks would empty quickly and staff should have monitored them more closely. The facility did not have a policy for supplemental oxygen use and did not provide documentation of staff education on standards of care for oxygen therapy.
Deficiencies in Personalized Care Plans for Residents
Penalty
Summary
The facility failed to develop and personalize comprehensive care plans for six out of fourteen residents reviewed, leading to deficiencies in meeting the residents' needs. For Resident #6, the care plan for anticoagulant therapy was incomplete, lacking details on the reason for the medication, specific side effects to monitor, and how to assess effectiveness. Similarly, Resident #25's care plan for antipsychotic medication was not personalized, missing the medication name, related diagnosis, and specific behaviors to monitor. Resident #40's care plan under hospice care was not individualized, failing to include interventions for pain management, emotional support, and coordination with hospice services. The Director of Nursing acknowledged the expectation for personalized care plans, particularly for psychotropic medications, but the care plans reviewed did not meet these standards. Resident #29's care plan did not address personalized interventions for dementia, wandering, and anxiety, despite the resident's severe cognitive impairment and mood symptoms. Resident #3's care plan lacked targeted interventions for dementia, personality disorders, and Parkinson's Disease, while Resident #32's care plan did not include personalized interventions for Alzheimer's Disease, cerebrovascular accident, anxiety, and depression. The MDS Coordinator admitted to still learning the process of updating care plans, and the facility lacked specific policies for initiating or revising care plans and MDS assessments, relying instead on general regulations.
Deficiency in Dietary Management Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service. Specifically, the Dietary Manager (DM) had passed the certification test but had not purchased the license, and therefore was not certified as an approved nutrition and food service manager. This was confirmed through a course completion certificate and the DM's own admission that she did not have a national certification. The facility's policy titled Personnel - General, dated 2021, indicated that the food and nutrition services department should be staffed with sufficient, competent, and supportive personnel to carry out its functions. However, the Administrator acknowledged that the DM was expected to have the correct dietary management certification, which was not the case.
Improper Preparation and Portioning of Diets
Penalty
Summary
The facility failed to properly prepare and serve pureed diets for two residents and did not serve appropriate portions for several others. Observations revealed that the cook, Staff A, did not measure the ingredients or the final volume of pureed food, which included carrots, bread, pork ribs, and macaroni. Instead, he used a basting spoon to add unmeasured amounts of food and milk into a blender, divided the mixture into bowls, and placed them on the steam table without ensuring the portions met the required measurements. This lack of measurement and adherence to the menu specifications resulted in improper preparation of pureed diets for the residents. Additionally, the facility did not serve the correct portion sizes for residents on regular and carbohydrate-controlled diets. During lunch service, the first 11 plates were prepared with partially full 4-oz servings of macaroni & cheese, green beans, and mixed vegetables, which did not align with the menu's specified portions. The Dietary Manager acknowledged the absence of a specific policy for the puree process and indicated that staff should follow the designated puree process and diet spreadsheet, which was not adhered to during the observed meal preparation and service.
Sanitation and Food Handling Deficiencies
Penalty
Summary
The facility failed to maintain sanitary practices in food storage, preparation, and service, as observed during a survey. Multiple instances of improper food storage were noted, including unlabeled and undated food items in refrigerators and freezers, and food stored directly on the floor. Additionally, staff were observed handling food without proper hand hygiene or glove changes, contributing to potential cross-contamination. For example, a cook was seen touching a garbage can and then handling food without changing gloves or washing hands. Further observations revealed unsanitary conditions in the kitchen, such as a fan blowing air into a cut-out section of the ceiling above the food serving area, and pieces of ceiling insulation falling onto the serving area. Staff were also seen using inappropriate surfaces for food preparation, such as placing a strainer in a sink designated for dirty dishes and using a piece of sheet metal on a food preparation counter. These actions were contrary to the facility's policies on food storage and handling. The facility's policies, which require food to be dated and stored off the floor, and mandate hand hygiene and prevention of cross-contamination, were not followed. The Dietary Manager confirmed that staff should adhere to these policies, yet multiple violations were observed, indicating a systemic issue with compliance in food safety practices.
Inadequate Infection Control and Water Management
Penalty
Summary
The facility failed to properly implement its Infection Prevention and Control Program (IPCP), as evidenced by several observations and staff interviews. Staff were observed not discarding Personal Protective Equipment (PPE) immediately after use, with isolation gowns hanging out of covered containers and on doors. Additionally, staff did not consistently perform hand hygiene, as seen when a Certified Nurse Aide (CNA) handled a resident's meal ticket and utensils without washing hands. The Infection Preventionist confirmed that PPE should be covered and not reused, aligning with the facility's policy. Furthermore, the facility did not have a comprehensive water management plan to address the risk of Legionella or other waterborne pathogens. The Maintenance Director was unfamiliar with the facility's water flow system and lacked a water management plan or completed water system flow and Legionella risk area documents. The water heater and storage tanks were set at temperatures that may not effectively control pathogen growth. The facility's policy required sound engineering and preventative maintenance to minimize Legionella exposure, but these measures were not in place.
Failure to Provide Timely Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) within the mandated 2 calendar days for two residents receiving skilled care under Medicare A. Resident #43 began receiving skilled care on May 2, 2024, with Medicare coverage continuing until May 20, 2024. Although a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was signed on May 17, 2024, the facility could not produce a signed NOMNC form. Instead, a typed name of the resident representative was noted as a telephone order on the same date. Similarly, Resident #44 received skilled care starting November 1, 2023, with Medicare coverage until January 4, 2024. The SNFABN was signed on December 21, 2023, but again, the facility failed to provide a signed NOMNC form, only noting a telephone order on the same date. The Social Services Director, who assumed the role in March 2023, stated she was initially trained to use only the SNF ABN form and was unaware of the NOMNC requirement. Upon learning about the NOMNC, she contacted residents or their representatives post-discharge to inform them about the form, backdating it to match the SNFABN signing date. Consequently, residents discharged during this period were not informed about their right to appeal to continue their skilled stay under Medicare.
Failure to Complete Mandatory Abuse Training
Penalty
Summary
The facility failed to ensure that two of the five staff members reviewed, identified as Staff L and Staff M, completed the mandatory two-hour Dependent Adult Abuse training within six months of their hire date. Staff L was hired on December 8, 2023, and Staff M on January 4, 2024. Upon review of their employee files on July 19, 2024, it was found that there was no documentation of the Iowa Department of Public Health approved Dependent Adult Abuse Mandatory Reporter training being completed by either staff member. The Business Office Manager attempted to locate the certificates on the same day but was unsuccessful by 5:00 pm. The facility's policy, dated January 10, 2022, requires each employee to complete this training within six months of hire and a recertification every three years thereafter.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies in their documented care needs and conditions. For one resident, the MDS inaccurately recorded a Brief Interview of Mental Status (BIMS) score indicating intact cognition, despite the resident having diagnoses of Alzheimer's disease, anxiety disorder, depression, and bipolar disorder. The MDS also failed to document the use of antidepressant medications and incorrectly noted the use of bed rails as a restraint, despite a side rail assessment indicating they were used to promote independence. Additionally, the facility did not document any gradual dose reduction (GDR) attempts for psychotropic medications, although psychiatric progress notes indicated that GDRs were clinically contraindicated. Another resident's MDS inaccurately documented the use of bed rails as a restraint, which the MDS Coordinator later identified as an error, stating the facility is restraint-free. The MDS Coordinator admitted to a lack of a tracking system for GDRs, leading to incorrect MDS entries. A third resident's MDS inaccurately reported severe cognitive impairment and failed to document an unstageable pressure ulcer, despite physician orders and care plans indicating its presence. The MDS Coordinator acknowledged being in training and unfamiliar with the process of updating care plans, and the Director of Nursing (DON) confirmed the absence of policies for initiating or revising care plans and MDS assessments.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to revise and update the care plan for two residents, leading to deficiencies in their care. Resident #37, who had severe cognitive impairment and multiple medical conditions, was found to have an unstageable pressure ulcer on the right lateral foot. Despite a physician's order for treatment, the care plan was not updated to reflect this condition. The nursing staff completed the treatment as ordered, and the area appeared healed upon assessment. However, the MDS Coordinator, who was still learning the process of updating care plans, did not ensure the care plan was revised to include the pressure ulcer. Resident #16, who had intact cognition, reported significant pain from a previous fall that resulted in a broken tailbone. Although the resident was receiving scheduled pain medication as ordered by the physician, the care plan was not updated to reflect this change in medication regimen. The resident expressed that the pain medication was not effective enough, impacting her ability to sit comfortably. The Director of Nursing acknowledged the lack of a specific policy regarding care plans, stating that the facility follows regulations and standards of care.
Failure to Provide Restorative Activities for Resident
Penalty
Summary
The facility failed to provide restorative activities for a resident, identified as Resident #22, to maintain a functional range of motion and prevent a decline in activities of daily living. The resident was dependent on staff for various activities such as bathing, dressing, bed mobility, transferring, and toileting, and had functional limitations in one upper and one lower extremity. Despite having a care plan that directed staff to perform range of motion exercises and a Restorative Nursing Program, the resident did not receive any Speech, Occupational, or Physical Therapies or Restorative Nursing Programs during the assessment period. Observations noted the resident's right wrist was contracted, and staff interviews revealed a lack of awareness and implementation of the restorative program. The Social Services director was unaware of the resident having a Restorative Program, and the Rehabilitation Director confirmed that the resident had not been screened for therapy during her tenure. The MDS Coordinator could not explain why the resident did not have a restorative program, despite acknowledging the resident's appropriateness for such a program. The facility's policy outlined a process for assessing and developing restorative programs, but it was not followed, leading to the deficiency in care for Resident #22.
Incomplete Nurse Staffing Information Posting
Penalty
Summary
The facility failed to complete and post nurse staffing information at the beginning of each shift, as required. On July 19, 2024, at 12:45 PM, the posted staffing sheet was found to have incomplete data for the day and evening shifts. Further review of the nurse staffing information binder at 2:30 PM revealed that all 17 staffing sheets for July 2024 were incomplete, and there was no staffing sheet available for July 17, 2024. The Director of Nursing (DON) stated that the staffing information sheet is initiated during the night shift, and the nurse for each shift is expected to complete and post the staffing information. However, on July 22, 2024, the DON admitted that the facility did not have a policy regarding the posting of staffing data.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature, as observed during a survey. On July 19, 2024, a cook prepared pureed pork ribs, carrots, and macaroni & cheese for two pureed lunch menus. The cook divided each menu item into separate bowls, heated the pureed carrots, and placed all six bowls in a pan on the steam table without checking the temperatures of the pureed items before placing them in the steam table pan. Later, the cook prepared a plate for a dietary aide to deliver to a resident. A temperature check revealed that the pureed pork ribs were at 129.4 degrees Fahrenheit and the pureed macaroni & cheese was at 80.1 degrees Fahrenheit, both below the required serving temperature of at least 135 degrees Fahrenheit as per the facility's policy. The dietary manager confirmed that staff should adhere to safe food temperature ranges.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to report an allegation of possible abuse or injury of unknown origin in a timely manner for a resident. The resident, who had moderately impaired cognition with a BIMS score of 12 out of 15, was diagnosed with cancer, Alzheimer's disease, COPD, and thoracogenic scoliosis. The resident was dependent on assistance for most activities of daily living. An incident occurred on 6/26/24, where the resident sustained an injury to the left elbow and accused a staff member of causing a fall. The facility's investigation notes indicated that the accused staff member was terminated on 7/01/24 for reasons unrelated to the incident. The Director of Nursing (DON) contacted the facility's corporate office on 7/01/24 regarding the necessity of reporting the incident to the State Agency. Initially, the corporate administration advised that it was not a reportable event. However, the reporting process to the State Agency began on 7/03/24, following further direction. The delay in reporting the incident to the proper authorities constitutes a deficiency in the facility's adherence to reporting requirements. The facility's administrator acknowledged that the facility should comply with the State Agency's reporting requirements.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to adequately supervise and provide a secure environment for a resident identified as an elopement risk. The resident, who had moderate cognitive impairment and a history of anxiety, managed to leave the facility unnoticed. The resident's care plan, which was revised to address elopement risks, included instructions for staff to check the wander guard every shift. However, documentation of these checks was incomplete, and the resident was able to remove the wander guard and exit the facility without triggering an alarm. On the day of the incident, the resident's daughter took him and his wife out for a walk, returning them to the facility later. The daughter mentioned that the resident watched her enter the door code, which he later used to exit the facility. Staff were unaware of the resident's absence until he returned with items from his home, indicating he had walked there and back. The staff did not hear any alarms or pages for a missing resident, and there was a lack of documentation for the required 15-minute visual checks following the incident. Interviews with staff revealed a lack of awareness and seriousness regarding the resident's elopement. Staff assumed the resident was with his daughter and did not verify his whereabouts. The facility's policy on missing residents and elopement was not effectively implemented, as evidenced by the incomplete documentation and lack of immediate response to the resident's absence. The resident's ability to leave the facility unnoticed highlighted deficiencies in supervision and security measures.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate pain management for two residents, leading to deficiencies in their care. Resident #16, who had a history of a broken tailbone, reported ongoing severe pain that was not effectively managed by the facility. Despite having an order for a lidocaine patch for lower back pain, the Treatment Administration Record (TAR) showed it was not utilized for several months. Additionally, there was a lack of documented pain assessments, with the last numerical pain assessment recorded in April 2024. Staff interviews revealed that the resident frequently complained of pain, yet there was no evidence that the physician was notified about the inadequacy of the pain management regimen. Resident #21, who was under hospice care, also experienced inadequate pain management. The resident's relative confirmed that the morning pain medication was not administered as scheduled. The resident had a history of cancer, Alzheimer's disease, COPD, and scoliosis, and reported almost constant pain. The Medication Administration Record (MAR) showed that the resident's Hydrocodone-Acetaminophen was administered late on numerous occasions. The average pain rating for the resident was 4.8 out of 10, indicating persistent pain issues. The Director of Nursing (DON) acknowledged that the facility did not have a specific policy addressing pain management, relying instead on general regulations. The lack of consistent pain assessments and timely administration of pain medication contributed to the deficiencies in managing the residents' pain effectively. Staff interviews highlighted a gap in communication and documentation, which further exacerbated the residents' pain management issues.
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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