Adel Acres
Inspection history, citations, penalties and survey trends for this long-term care facility in Adel, Iowa.
- Location
- 1919 Greene Street, Adel, Iowa 50003
- CMS Provider Number
- 165555
- Inspections on file
- 24
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Adel Acres during CMS and state inspections, most recent first.
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 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 with moderate cognitive impairment and multiple chronic conditions, including renal insufficiency and diabetes, was receiving a diuretic and had a care plan and physician order requiring daily weights and physician notification for specified weight changes. During one month, the MAR documented several significant daily weight fluctuations exceeding the ordered parameters, but the EHR contained no evidence that the physician was notified or that the weights were sent to the clinic as ordered. In an interview, the DON acknowledged that staff did not follow the physician’s orders, despite a facility policy requiring consistent provision of physician‑ordered services according to professional standards of quality.
Staff failed to follow the facility’s pureed diet policy when preparing lunch for two residents on a puree diet. A dietary aide pureed Salisbury steak for two residents but did not measure the final volume or use the Pureed Diet Portion Sizes/Scoops chart to determine the correct scoop size, instead assuming it would match the pureed cauliflower and using a blue #16 scoop (2.66 oz) for both items. For the cauliflower, the aide did measure the volume and identified that a #6 scoop (5.3 oz) was indicated, but still used the smaller scoop. After service, there were leftover portions of both pureed cauliflower and meat, indicating incorrect portioning. The RD confirmed staff are required to use the volume method and that the aide did not follow the policy steps for the pureed meat.
A resident with diabetes and an infection did not receive ordered blood sugar checks before meals and at bedtime, nor were IV antibiotics administered as prescribed. Documentation showed missed BS checks and IV antibiotic doses, with no evidence that the provider was notified when the medication could not be given due to lack of IV access or medication availability. The resident experienced persistently high blood sugars and was re-hospitalized for sepsis.
Two residents with severe cognitive impairment experienced falls followed by significant changes in condition, including altered mental status and increased pain. Despite staff observations of these changes, there were delays in notifying providers and escalating care, resulting in one resident being diagnosed with a brain bleed after family intervention and another with a hip fracture after several days of pain and functional decline. Documentation and communication lapses contributed to the delayed interventions.
A resident with diabetes, sepsis, and renal failure experienced repeated episodes of critically high blood sugar and required IV antibiotics, but staff were unable to obtain timely physician orders or responses despite multiple attempts. LPNs and the DON reported ongoing difficulties reaching the provider, leading to delays in care, unclear medication orders, and lapses in the management of urgent medical needs.
A resident with multiple chronic conditions did not receive weekly skin assessments or timely intervention when skin breakdown occurred, and staff failed to document the administration of oxygen therapy when the resident's O2 saturation fell below ordered parameters. Observations and interviews confirmed open wounds and missed documentation, with the DON unaware of the full extent of the resident's skin issues until prompted by surveyors.
Staff left a shower room door open with water running and a wet floor, while a resident with severe cognitive impairment and hemiplegia was present in the hallway. Hallways were also observed to be cluttered with wheelchairs, lifts, and carts, making navigation difficult for residents. Staff and leadership acknowledged these hazards and the lack of available policy on safety measures.
Staff, including the Dietary Manager, LPNs, CNAs, and a cook, were observed touching the tops of plates and making direct contact with food while serving meals, and did not consistently perform hand hygiene after resident contact or when switching between assisting different residents. Food that had been touched by staff was not replaced and was consumed by residents, despite facility policies requiring hand sanitization and avoidance of direct contact with food.
Staff failed to follow enhanced barrier precautions and infection control protocols for two residents requiring such measures. For a resident with a suprapubic catheter, staff did not wear a gown, did not use a barrier under the urine collection graduate, and did not cleanse the catheter port with alcohol as required. In a separate incident, staff prepared washcloths for perineal care in a handwashing sink shared by another resident, contrary to infection control policy. Interviews revealed inconsistent understanding of EBP requirements among staff, and the DON confirmed these practices did not meet facility expectations.
A resident with a history of stroke, lymphedema, and impaired range of motion did not consistently receive recommended restorative care after discharge from PT. The care plan lacked details for a functional maintenance program, and documentation showed ambulation and exercise activities were inconsistently performed or not attempted. Staff interviews revealed the absence of a restorative aide, resulting in the resident not receiving the necessary interventions to maintain or improve mobility.
Two residents experienced medication administration errors, resulting in a medication error rate above 5%. One resident with diabetes received an incorrect insulin dose based on an outdated sliding scale and improper use of an insulin flexpen by an LPN. Another resident with GERD and dysphagia was given crushed omeprazole DR, contrary to pharmacy guidance and facility policy, by a certified medication aide. Staff interviews revealed inconsistent practices in verifying orders and medication administration procedures.
A resident with diabetes received an incorrect insulin dose when an LPN administered insulin based on an outdated sliding scale order taped inside the supply bin, rather than the current physician order in the EMAR. The LPN also failed to prime the insulin flexpen as required by manufacturer instructions. Inconsistent practices for updating and verifying sliding scale orders, along with lack of staff awareness of proper insulin pen technique, led to this medication error.
Two residents on pureed diets were served incorrect portion sizes during a lunch meal, as staff did not use the required scoop sizes for pureed chicken and peas according to the posted serving chart and facility policy. The dietary staff blended menu items together and served portions that did not meet the specified requirements, and staff were unsure of the correct serving sizes to use.
A resident's personally identifiable health information, including details about a skin graft and care restrictions, was posted in a public area where visitors could view it. Staff acknowledged the information should have only been stored in the resident's chart or EHR, in line with the facility's privacy policy.
The facility failed to secure medication carts, leaving them unlocked and unattended. A CMA was observed preparing medications and leaving the carts unlocked while entering the dining room. An RN later locked one cart but confirmed that carts should be locked when unattended. The facility's policy requires medication carts to be locked when not attended by authorized personnel.
The facility failed to secure resident-identifiable information when two unlocked laptops displaying residents' information were left unattended on medication carts in a dining room. A CMA turned her back to the laptops while administering medication, and an RN later locked one of the screens. The facility lacked a policy on securing resident information.
A resident with intact cognitive skills expressed a desire to wear personal clothing instead of a hospital gown, but the facility failed to honor this preference. Staff interviews revealed misunderstandings about the resident's wishes, with some citing behavioral issues as the reason for the gown. Documentation was incomplete, lacking records of behaviors or interventions related to the resident's clothing choice, despite the facility's policy emphasizing residents' rights to personal possessions.
A resident with severely impaired cognition and a history of falls was found on the floor after a fall, with a tipped-over wheelchair nearby. The care plan required the bathroom light to be left on at all times to prevent falls, but observations showed the light was off on two occasions. The resident suffered a hip fracture, requiring surgery. Staff interviews and observations confirmed the care plan was not followed, as acknowledged by the DON.
A resident with severe cognitive impairment and multiple medical conditions fell in their room, but the facility failed to conduct and document the required neurological checks. The care plan did not include directives for post-fall neuro checks, and the necessary documentation was missing, indicating a lapse in following the facility's policy.
The facility failed to adhere to infection control policies during medication administration and resident feeding. A CMA improperly handled a fallen pill, and a CNA did not perform hand hygiene between feeding two residents. Additionally, a mechanical lift was not cleaned between uses for two residents, contrary to the facility's standard precautions policy.
A resident with severe cognitive impairment and multiple medical conditions was not consistently provided with supplemental oxygen as ordered by the physician. The facility's records lacked documentation of pulse oximetry results and the use of as-needed oxygen, and the resident was observed without oxygen therapy on several occasions. Staff interviews confirmed that the resident was not assessed for pulse oximetry monitoring, leading to a failure in following physician orders.
The facility failed to submit accurate PBJ staffing data, showing excessively low weekend staffing and insufficient 24-hour nursing coverage on 19 dates. Administrative staff worked as CNAs and nurses but were salaried and did not clock in, leading to report inaccuracies. The corporate office submitted the incorrect data.
The facility failed to ensure dietary staff followed food safety procedures, risking cross-contamination and foodborne illness. A dietary aide wore inappropriate clothing and handled glasses improperly, while a cook did not wash hands between tasks or check hamburger temperatures. The dietary manager acknowledged these issues.
The facility failed to ensure proper completion and clarification of SNF ABN forms for two residents. One resident, with no cognitive impairment, signed the form without choosing an option, and the facility did not document any follow-up. Another resident, with severe cognitive impairment, had their representative choose an option, but the facility did not document the provision of care or billing to Medicare.
The facility failed to conduct necessary background checks for a CNA before rehiring, as required by their abuse prevention policy. The CNA's file lacked documentation of Iowa Criminal History, Sex Offender Registry, Central Abuse Registry, and Professional License checks. The Business Office Manager confirmed the oversight, and the Administrator noted that checks should occur if the employment gap exceeds 30 days, but no specific pre-employment policy was in place.
The facility failed to update Level 2 PASSR evaluations for two residents after changes in diagnoses or treatment. One resident with severe cognitive impairment and multiple mental health diagnoses had medication changes not reflected in an updated PASSR. Another resident, also with severe cognitive impairment, had outdated PASSR documentation that did not include current mental health diagnoses or hospice transition. The facility lacked a specific policy for PASSR completion, leading to these deficiencies.
A resident with severe cognitive impairment and an indwelling urinary catheter did not receive appropriate catheter and perineal care. The catheter bag was observed hanging uncovered with tubing touching the floor. Staff failed to perform complete perineal care after a bowel movement, using the same cloth for both anal and perineal areas without changing gloves or performing hand hygiene. The facility's policies on catheter and incontinent care were not followed.
A resident with severe cognitive impairment and malnutrition did not receive the recommended dietary interventions, including ice cream at lunch, as part of their nutritional plan. The facility also failed to document the amount of nutritional supplement given, despite the resident's history of significant weight loss.
The facility failed to complete and submit VA forms for two residents. One resident did not have the VA paperwork completed upon admission, and another resident's eligibility paperwork was not submitted to the VA. The Administrator confirmed these deficiencies, noting that the Social Worker is responsible for these tasks.
Two residents with severe cognitive impairment received inadequate infection control care. Staff used improper techniques, such as not changing gloves between cleaning different body areas and disposing of care water inappropriately. These actions were against the facility's policies, increasing the risk of infection.
The facility failed to identify and treat pressure ulcers and other skin impairments for a resident, leading to untreated pressure ulcers on the right hip, both heels, and venous insufficiency ulcers on both feet. Clinical records and staff interviews revealed inadequate skin assessments and documentation, with staff unaware of the resident's significant skin conditions.
The facility failed to ensure all required members, including the DON/IP, attended the quarterly QAA meetings, with the DON/IP absent for 2 of the 4 meetings reviewed. This was confirmed by the Administrator and the review of QAPI meeting sign-in sheets.
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.
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 Notify Physician of Significant Weight Changes for Resident on Diuretic
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for monitoring and reporting significant weight changes for a resident receiving a high‑risk medication. The resident had moderate cognitive impairment with a BIMS score of 8 and medical diagnoses including renal insufficiency, hypertension, diabetes mellitus, hyperlipidemia, and stroke. The resident’s MDS indicated use of a diuretic, and the care plan identified a problem of edema/fluid volume overload with goals for stable fluid volume and interventions that included informing the physician of increased edema, obtaining labs as ordered, administering medications as ordered while monitoring for side effects and effectiveness, and promptly notifying the physician of specified clinical changes. A physician order dated 12/8/25 directed staff to obtain daily weights prior to eating and drinking, notify the physician of weight changes of 3 pounds in 1 day or 5 pounds in 7 days, and send the information to the clinic for review. Review of the March 2026 MAR showed multiple significant daily weight fluctuations for this resident, including a decrease from 172.3 pounds to 165.7 pounds (6.6 pounds) in one day, an increase from 165.7 pounds to 170.7 pounds (5 pounds) in one day, and an increase from 169.6 pounds to 173.9 pounds (4.3 pounds) in one day. Review of the EHR revealed no documentation that the physician was notified of these weight changes as required by the 12/8/25 order. In an interview, the DON confirmed that the physician had not been notified of the March weight changes in accordance with the order and acknowledged that staff did not follow the physician’s orders, despite the facility’s policy on Provision of Physician Ordered Services, which states its purpose is to provide a reliable process for proper and consistent provision of physician‑ordered services according to professional standards of quality.
Failure to Follow Puree Diet Portioning Procedure for Two Residents
Penalty
Summary
The deficiency involves failure to follow the facility’s pureed diet policy and procedure for determining appropriate portion sizes for two residents on a pureed diet. During a lunch meal observation, a dietary aide pureed Salisbury steak for two pureed-diet residents but did not measure the pureed meat in a volume measuring cup before service, contrary to policy. Instead, the aide transferred the pureed meat directly from the food processor to a serving dish on the steam table and selected a blue #16 scoop (2.66 oz) for serving, based on the assumption that the meat portion would be the same as the pureed cauliflower. The aide reported having placed two pieces of Salisbury steak into the food processor but did not calculate the final volume or determine the correct scoop size using the facility’s Pureed Diet Portion Sizes/Scoops chart. In contrast, the aide followed the required steps for the pureed cauliflower by pureeing it, transferring it to a measuring cup, obtaining the volume, and then using the chart to select the correct scoop size, which was identified as a #6 scoop (5.3 oz). Despite this, the aide used the same blue #16 scoop for both the cauliflower and the meat. After lunch service, the aide confirmed there was approximately half a serving of pureed cauliflower and about one full serving of pureed Salisbury steak left over, even though only two residents were on a pureed diet. The registered dietitian later confirmed that staff are expected to use the volume method and acknowledged that the aide did not measure the pureed meat and that there should not have been leftover pureed meat if the correct scoop size had been used. The facility’s written policy requires adding the correct number of servings to the processor, pureeing to proper consistency, measuring the final volume, using the chart to determine serving size, and labeling with serving size, steps that were not followed for the pureed meat.
Failure to Follow Physician Orders for Diabetic Monitoring and IV Antibiotic Administration
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes and an infection, specifically by not completing required blood sugar (BS) checks before meals and at bedtime, and by not administering intravenous (IV) antibiotics as ordered. Clinical record review showed that after hospital discharge, the resident had orders for diabetic monitoring and IV antibiotics, but the Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of the required BS checks. Additionally, the IV antibiotic was only administered once out of five ordered days, with multiple entries noting the medication was not given due to lack of IV access or medication not being available. There was also a failure to notify the physician when the IV antibiotic could not be administered due to the absence of IV access or medication. Nurses' notes documented several instances where the resident's IV was not in place or had been removed, and the antibiotic was not given, but there was no documentation that the provider was notified as required. The resident experienced persistently high blood sugar levels, with several readings above 400, and again, there was no documented notification to the provider as ordered. The resident was eventually re-hospitalized for sepsis and had high blood sugar levels upon readmission. Staff interviews confirmed that the expected protocol would be to clarify orders and notify the provider if medications were unavailable or if there were issues with IV access. The facility's policies and job descriptions require prompt implementation of physician orders and communication with providers regarding changes in resident condition or inability to administer medications. Despite these requirements, the facility did not ensure that physician orders were followed or that the provider was notified of significant issues, contributing to the resident's deterioration and subsequent hospitalization.
Failure to Promptly Identify and Intervene After Resident Falls
Penalty
Summary
The facility failed to promptly identify and intervene for changes in condition following falls for two residents with severe cognitive impairment. In the first case, a resident with a history of multiple falls, severe cognitive impairment, and significant neurological diagnoses experienced a witnessed fall in which staff observed the resident hit her head. Despite multiple staff noting changes in the resident's behavior—including increased sleepiness, bulging eyes, and altered responsiveness—there was no documentation of provider notification regarding these changes. The resident was later taken to the hospital by family, where a brain bleed was diagnosed, and subsequently passed away due to complications from blunt force trauma to the head. In the second case, another resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls over a short period. Staff documented initial assessments and follow-up checks, but over the next days, the resident developed increasing pain, bruising, and difficulty bearing weight. Multiple CNAs reported the resident's pain and functional decline to nursing staff, but there was a delay in further assessment and provider notification. Only after significant pain and inability to bear weight were observed did the facility obtain an x-ray, which revealed a hip fracture requiring surgical intervention. Both cases demonstrate failures in timely recognition and escalation of significant changes in condition following falls, despite staff observations and facility policies requiring provider notification for such events. Documentation gaps and communication breakdowns between CNAs, nurses, and providers contributed to delays in appropriate assessment and intervention for these residents.
Failure to Ensure Timely Physician Oversight and Response for Resident Care
Penalty
Summary
The facility failed to ensure that a resident was under the care of a physician who would provide timely orders and respond promptly to notifications regarding elevated blood sugars, abnormal lab results, and the administration of intravenous (IV) medication for infection. The resident in question had significant medical conditions, including diabetes, septicemia, renal failure, and aphasia, and required complex care such as insulin management and IV antibiotics following a hospital discharge for sepsis and a large retroperitoneal abscess. The discharge summary included a specific order for daily IV antibiotics, but documentation showed repeated issues with the resident removing IV lines and delays in replacing them, as well as changes in medication orders without clear or timely communication from the provider. Nursing notes and medication records revealed multiple instances where the resident experienced critically high blood sugar levels, with staff making repeated attempts to contact the provider for guidance. In several cases, messages were left without timely responses, and there were documented difficulties in reaching the provider or receiving actionable orders. Staff interviews confirmed that the provider was often unresponsive, sometimes taking days to return calls, and that staff had to escalate urgent issues to the Medical Director or repeatedly attempt contact. There were also communication gaps regarding new medication orders and diagnostic results, with staff sometimes unaware of new orders or not receiving reports directly. The facility's policy required that a physician or nurse practitioner supervise residents' medical care and be available 24 hours a day for emergency care. However, both nursing staff and the Director of Nursing reported ongoing problems with provider responsiveness and unclear points of contact, resulting in delays in care and uncertainty about the resident's treatment plan. These failures led to lapses in the timely management of the resident's acute and chronic medical needs.
Failure to Complete Weekly Skin Assessments and Document Oxygen Therapy Administration
Penalty
Summary
Nursing staff failed to complete weekly skin assessments and provide timely intervention for a resident who exhibited a change in skin condition. The resident, who had multiple diagnoses including heart failure, stroke, chronic lung disease, and dementia, was care planned for impaired skin integrity and required weekly skin observations and specific wound care treatments. Despite these orders, documentation showed that the last weekly wound observation was completed several weeks prior to the survey, and there was a lack of documentation regarding open wound areas in the progress notes during a period when the resident developed excoriation and open areas on the buttocks. Staff interviews and observations confirmed that the resident had open wounds that were not promptly assessed or documented, and the DON was unaware of the open areas until prompted by the surveyor. Additionally, the facility failed to document the administration of oxygen therapy when the resident's oxygen saturation dropped below the physician-ordered parameters. The resident had orders for oxygen to be applied as needed to maintain saturation above 90%, but multiple recorded pulse oximetry readings showed levels below this threshold without corresponding documentation that oxygen was administered. Observations and interviews revealed that the resident often removed the oxygen, but there was no documentation of refusals or staff interventions in the medical record as required by facility policy. The facility's policies required weekly skin evaluations and documentation of any abnormalities, as well as notification and documentation of significant changes in condition. However, the records lacked evidence of consistent skin assessments, timely wound care interventions, and appropriate documentation of oxygen therapy administration or refusals. These failures resulted in a lack of timely response to changes in the resident's condition and incomplete records regarding the care provided.
Failure to Prevent Accident Hazards and Maintain Safe Environment
Penalty
Summary
Staff failed to implement safety measures for residents at risk of injury, as evidenced by multiple direct observations and staff interviews. During a continuous observation, the shower room door in the South Hall was left open with the water running and the floor visibly wet, while several residents, including one with severe cognitive impairment and hemiplegia, were present in the hallway. Surveyors had to position themselves near the shower room to prevent this resident from wandering into the hazardous area. Additionally, hallways throughout the facility were heavily cluttered with wheelchairs, mechanical lifts, and carts, further impeding safe passage for residents. Staff interviews confirmed that the shower room door should not have been left open, especially with the water running, and acknowledged the hazard this posed to cognitively impaired residents. Staff also recognized the ongoing issue of hallway clutter, noting the facility's limited space for storage. The Director of Nursing and Administrator both acknowledged these deficiencies, and it was noted that a policy regarding these safety measures was not available for review.
Failure to Follow Food Handling and Hand Hygiene Standards During Meal Service
Penalty
Summary
Staff failed to adhere to professional standards for food service safety during meal service, as observed over two days. Multiple staff members, including the Dietary Manager, LPNs, CNAs, and a cook, were seen touching the tops of plates and making direct contact with resident food while serving meals. Staff were also observed not performing hand hygiene after making direct contact with residents or switching between assisting different residents with eating. In several instances, food that had been touched by staff was not replaced and was consumed by residents. Interviews with staff confirmed awareness of the facility's expectations and policies, which direct staff to avoid touching eating surfaces, sanitize hands after resident contact, and replace food if direct contact occurs. Despite this, staff acknowledged lapses in following these procedures, such as not sanitizing hands between feeding different residents and not avoiding contact with food. The facility's policy on food handling and glove use requires hand sanitization and glove use when direct contact with food is necessary, but these standards were not consistently followed during the observed meal services.
Failure to Follow Enhanced Barrier Precautions and Infection Control During Resident Care
Penalty
Summary
Facility staff failed to follow enhanced barrier precautions (EBP) and infection control protocols for residents requiring such measures. For one resident with a suprapubic catheter and a history of chronic urinary tract infections, staff did not don a gown as required during high-contact care activities, such as emptying the catheter. The staff member only wore gloves, placed the urine collection graduate directly on the carpeted floor without a barrier, and did not cleanse the catheter port with alcohol before or after emptying the catheter. The staff member also used gloved hands to open the bathroom door and handled the graduate and bathroom fixtures without changing gloves or using additional protective measures. These actions were inconsistent with the facility’s EBP policy and the indwelling catheter competency checklist, both of which require the use of a gown, gloves, and a disposable barrier during such procedures. Interviews with facility staff, including a CNA, LPN, RN, and the DON, revealed inconsistent understanding and application of EBP requirements. While some staff indicated that gowns, gloves, masks, and goggles should be used for catheter care, others stated that only gloves were necessary, depending on the resident’s illness or immune status. The DON confirmed that EBP, including gown and gloves, was required for residents with catheters or wounds, and that the observed practices did not meet facility expectations. In a separate incident, staff failed to maintain proper infection control during incontinence care for another resident with impaired skin integrity and open areas on the buttocks. Staff prepared washcloths for perineal care by placing them in a sink used for handwashing, which was also shared by the resident’s roommate. The DON, who also serves as the facility’s Infection Preventionist, confirmed that washcloths should not be left in a handwashing sink, as it is considered a dirty area. These lapses in infection control practices were directly observed during care and confirmed through staff interviews.
Failure to Implement Restorative Program for Resident with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve range of motion (ROM) and mobility for a resident with a history of cerebrovascular accident (CVA), lymphedema, and a chronic non-pressure ulcer. The resident had documented impaired ROM on one side of the body and required varying levels of assistance for ambulation and transfers. After discharge from physical therapy, the resident was recommended for a functional maintenance program (FMP) that included ambulation with a four-wheeled walker and use of an exercise bike for upper and lower extremity ROM. However, the care plan did not include details about the resident's ambulation status or a restorative or functional maintenance exercise program. Review of the resident's records showed inconsistent implementation of the recommended FMP. Documentation indicated that ambulation and exercise activities were either not attempted, refused, or inconsistently performed, with only two recorded uses of the therapy bike over several months. The resident reported that staff were often too busy to assist with walking and that he spent most of his day sitting, which contributed to the development of a sore on his buttock. Observations confirmed that the resident was frequently seated in his room or recliner, and staff interviews revealed that the facility did not have a restorative aide to implement or oversee restorative programs. Therapy staff confirmed that recommendations for FMPs were provided to nursing, but the frequency and implementation were left to nursing staff discretion. The facility's policy required that therapy referrals for restorative programs be implemented by a restorative nurse or aide, but in practice, there was no designated staff to carry out these programs. As a result, the resident did not consistently receive the restorative care necessary to maintain or improve functional abilities as recommended by therapy.
Medication Error Rate Exceeds 5% Due to Insulin and Omeprazole Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by 2 errors out of 30 observed medication administration opportunities, resulting in a 6.67% error rate. One incident involved a resident with diabetes who was prescribed Novolog insulin via a sliding scale. The nurse administered the insulin dose based on an outdated sliding scale taped inside the resident's supply bin, rather than the current order in the electronic medication administration record (EMAR). Additionally, the nurse did not prime the insulin pen prior to administration, contrary to manufacturer instructions. Interviews revealed inconsistent practices among staff regarding verification of insulin orders and updating of sliding scale references in the medication bins, with some staff relying on printed orders and others on the EMAR. The Director of Nursing acknowledged that the process for updating sliding scale orders in the bins was not consistently followed, and there was no facility policy for insulin flexpen administration. Another error involved a resident with GERD and dysphagia who was prescribed omeprazole delayed release (DR) capsules to be administered in the morning. The certified medication aide crushed the omeprazole DR capsule along with other medications and administered the mixture with applesauce while the resident was eating breakfast. According to the pharmacist, omeprazole DR should not be crushed, as this alters its delayed-release properties, and it should be given 30 to 60 minutes before a meal. Facility policy also states that long-acting or enteric-coated medications should not be crushed and that alternatives should be sought if necessary, with pharmacist consultation required. Both incidents demonstrate failures to follow physician orders, manufacturer instructions, and facility policy regarding medication administration. The errors were directly observed during surveyor review, and staff interviews confirmed lapses in verifying current orders and proper medication administration techniques. The facility's lack of a specific policy for insulin flexpen use and inconsistent updating of medication instructions contributed to the deficiencies.
Failure to Administer Insulin per Physician Orders and Manufacturer Instructions
Penalty
Summary
A deficiency occurred when staff failed to administer insulin according to the physician's sliding scale orders and manufacturer instructions for a resident with diabetes. The resident's care plan required staff to administer diabetes medication as ordered and to educate caregivers on correct glucose monitoring and insulin injection protocols. However, the sliding scale insulin order taped inside the resident's plastic supply bin was outdated and did not match the current physician's order in the electronic medical record (EMAR). On the day of observation, an LPN administered 2 units of insulin based on the outdated sliding scale in the bin, rather than the 3 units indicated by the current order and EMAR for the resident's blood sugar reading of 198. The LPN was unaware of the discrepancy and did not verify the dose with the EMAR before administration. Additionally, the LPN did not follow manufacturer instructions for using the Novolog insulin flexpen. The insulin pen was not primed prior to administration, and the LPN was not aware that priming was required to ensure the correct dose was delivered. The facility did not have a specific policy for insulin flexpen administration, and staff relied on both printed sliding scale orders in supply bins and the EMAR, leading to inconsistencies. Interviews with other nursing staff revealed varying practices, with some staff always checking the EMAR and others relying on printed orders in the bins, which were not always updated when orders changed. The Director of Nursing acknowledged that the process for updating sliding scale orders in the bins was not consistently followed, especially after recent order changes. The lack of a standardized process for ensuring that printed orders matched the EMAR, combined with insufficient staff education on insulin pen administration, contributed to the medication error. The facility's policy required medications to be administered as prescribed and for staff to verify orders, but this was not consistently implemented in practice.
Failure to Serve Correct Pureed Diet Portion Sizes
Penalty
Summary
The facility failed to serve the appropriate portion sizes for two residents on pureed diets during a lunch meal. The planned menu called for specific items and portion sizes, including chicken, peas, and a dinner roll, to be served in pureed form. During meal preparation, staff blended three chicken breasts and three dinner rolls together, then pureed peas separately, but did not use the correct scoop sizes as indicated by the posted serving chart. Instead of the required #6 scoop (5 1/3 oz.) for pureed chicken and #8 scoop (4 oz.) for pureed peas, staff used a #8 scoop (4 oz.) for chicken and a #12 scoop (2 1/2-3 oz.) for peas. Staff involved in meal preparation were unsure of the correct scoop sizes and relied on a book for guidance, but did not follow the posted chart or the facility's policy for determining portion sizes. The consulting dietician confirmed that staff were expected to follow the menu and serve the proper serving sizes, and noted that the dinner roll and chicken should have their serving sizes combined when pureed together. The facility's policy required staff to follow recipe portion sizes, blend the correct number of portions, and divide the total volume by the number of portions to determine serving size. These procedures were not followed, resulting in residents on pureed diets receiving incorrect portion sizes for their meals.
Resident Health Information Posted in Public Area
Penalty
Summary
A deficiency occurred when personally identifiable health information for one resident was posted in a public area accessible to visitors. Specifically, a note containing the resident's full name, details about a recent skin graft, the presence of a drainage port, and bathing restrictions was taped to the staff schedule, which faced the dining room. This information was visible to anyone in the facility, including visitors, until it was removed after the lunch dining service. The care plan for the resident did not specify bathing instructions, but the posted note included sensitive care details. Multiple staff members acknowledged awareness of the posted information, with some expressing concern that it should not have been displayed publicly. Staff interviews confirmed that resident-identifiable information is only to be stored in resident charts or the electronic health record, not in plain view. The facility's privacy policy, last reviewed in January 2025, requires limiting the use and disclosure of personal health information in accordance with HIPAA regulations, and all staff are responsible for adhering to this policy.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to secure prescribed medications from unauthorized access, as observed during a survey. On December 16, 2024, at 9:03 AM, two medication carts were left unlocked in front of the nurses' station, facing the dining room. Staff A, a Certified Medication Aide (CMA), was seen preparing medications at one of the carts and then entered the dining room, leaving both carts unattended and unlocked. At 9:06 AM, Staff B, a Registered Nurse (RN), approached one of the carts, placed an item inside, locked it, and then walked away. Later, at 12:40 PM, Staff B confirmed that medication carts should be locked when unattended. On December 17, 2024, at 8:49 AM, Staff A acknowledged that the cart should have been locked and admitted to forgetting to do so the previous day. The facility's Administrator also confirmed that medication carts should be locked when not attended. The facility's policy, revised in November 2018, mandates that medication rooms, carts, and supplies be locked when not attended by authorized personnel.
Failure to Secure Resident Information
Penalty
Summary
The facility failed to protect resident-identifiable information, as observed during a survey. On December 16, 2024, at 9:03 AM, two unlocked laptops were left unattended on medication carts by a Certified Medication Aide (CMA), with their screens facing an occupied dining room, displaying multiple residents' information. The CMA turned her back to the laptops while administering medication to a resident. At 9:06 AM, a Registered Nurse (RN) approached one of the laptops and locked its screen. Later, the RN confirmed that both the laptop screen and cart should be locked when unattended. On December 17, 2024, the CMA admitted forgetting to lock the cart and laptop. The Director of Nursing emphasized the importance of maintaining HIPAA compliance by minimizing or closing laptops when unattended. The facility lacked a policy on securing resident information.
Failure to Honor Resident's Clothing Choice
Penalty
Summary
The facility failed to honor a resident's right to choose personal clothing, as evidenced by the case of a resident who was consistently dressed in a hospital gown against his expressed wishes. The resident, who had intact cognitive skills as indicated by a Brief Interview for Mental Status (BIMS) score of 14, expressed a desire to wear normal clothes instead of the hospital gown he was observed wearing during multiple interviews. Despite his clear preference, staff interviews revealed a misunderstanding of the resident's wishes, with some staff believing it was his preference to wear the gown, while others cited behavioral issues as the reason for the gown. The facility's documentation was incomplete and inconsistent, failing to record any behaviors or interventions related to the resident's clothing preferences. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of any refusal to get dressed, and there were missing entries for several days. The Care Plan and other records did not document any behaviors or interventions related to the resident's clothing choice, despite staff claims of behavioral issues. The Director of Nursing acknowledged the documentation gaps and stated that her expectation was for complete and accurate documentation, including tracking of any behaviors and interventions. Interviews with staff members revealed a lack of communication and understanding regarding the resident's clothing preferences. Some staff believed the hospital gown was used as a behavioral intervention, while others thought it was the resident's choice. The Director of Nursing expected staff to honor residents' clothing choices and document any refusals or interventions, but the facility's records did not reflect this practice. The facility's policy on resident rights emphasized the importance of allowing residents to retain and use personal possessions, but this was not upheld in the case of the resident in question.
Failure to Implement Care Plan for Resident with Fall Risk
Penalty
Summary
The facility failed to implement the care plan for a resident with severely impaired cognition and a history of falls. The resident, who had multiple medical conditions including chronic kidney disease, diabetes, and a history of strokes, was found on the floor after a fall, with a tipped-over wheelchair nearby. The care plan, revised after the incident, directed staff to leave the resident's bathroom light on at all times to prevent further falls. However, observations on two separate occasions revealed that the bathroom light was off, contrary to the care plan instructions. The resident experienced significant pain and was later diagnosed with a subcapital femoral neck fracture, requiring surgical intervention. Despite the care plan's clear instructions, staff failed to ensure the bathroom light was left on, as evidenced by the observations and staff interviews. The Director of Nursing acknowledged that staff should follow the care plan, indicating a lapse in adherence to the established care protocols designed to prevent such incidents.
Failure to Document Post-Fall Neurological Checks
Penalty
Summary
The facility failed to provide appropriate assessment and interventions for a resident who experienced a fall. The resident, who had severely impaired cognition and multiple medical conditions including chronic kidney disease, diabetes, and a history of strokes, fell in their room at 2:12 AM. Despite the resident's history of falls and the presence of an anti-rollback bar on their wheelchair, the facility did not conduct or document the required neurological checks following the fall. The resident's care plan did not include directives for staff to perform neuro checks after a fall, which is a critical oversight given the resident's medical history and cognitive impairment. The facility's policy required a detailed neurological evaluation to be performed and documented over a 72-hour period following a fall. However, the electronic health record lacked documentation of these checks, and the staff responsible for scanning documents into the system confirmed that the neuro check sheets were missing and could not be located. The Director of Nursing acknowledged that staff should have documented the post-fall neuro assessments and maintained the paperwork, but the necessary documentation was not available, indicating a lapse in following the facility's policy and procedures for post-fall care.
Infection Control Deficiencies in Medication Administration and Equipment Use
Penalty
Summary
The facility failed to implement its infection control policy during medication administration and resident feeding. A Certified Medication Aide (CMA) was observed preparing medication for a resident when a pill fell into the top drawer of the medication cart. The CMA picked up the pill with her bare hand and placed it back into the resident's medication cup, contrary to the facility's policy that requires discarding any medication that falls outside the resident's cup. Both the Registered Nurse (RN) and the CMA acknowledged that the medication should have been discarded. Additionally, a Certified Nurse Aide (CNA) assisted two residents with eating without performing hand hygiene between feeding each resident, which is against the facility's standard precautions policy. The facility also failed to clean a mechanical lift between uses for two residents. A CNA and a Certified Occupational Therapy Assistant (COTA) used the mechanical lift to transfer one resident and then placed it in the hallway without cleaning it. Later, the same lift was used to transfer another resident without being disinfected in between uses. The Director of Nursing (DON) confirmed that the staff should have wiped down the equipment with disinfectant between resident uses, as per the facility's policy on standard precautions.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for a resident who required supplemental oxygen to maintain oxygen saturation levels above 90%. The resident, who had severe cognitive impairment and multiple medical conditions including heart failure, end-stage renal disease, and chronic obstructive pulmonary disease, was observed without oxygen therapy on several occasions. The Treatment Administration Record (TAR) lacked documentation of pulse oximetry results and the use of as-needed oxygen from early June to early July, despite physician orders indicating the necessity of supplemental oxygen. Observations and staff interviews revealed that the resident was often without oxygen therapy, and the oxygen concentrator was not in use or properly set up. The MDS Coordinator confirmed that the resident's oxygen saturation was below the required level when checked, and the facility's policy on physician orders was not followed. The staff admitted that the resident was not assessed for pulse oximetry monitoring during the specified period, leading to a failure in implementing the physician's orders as per professional standards and guidelines.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing reports for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the quarter from October 1 to December 31. The report indicated excessively low weekend staffing and a failure to provide 24-hour licensed nursing coverage on 19 specific dates. The facility's daily assignment sheets showed that the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Minimum Data Set (MDS) Coordinator covered shifts as Certified Nursing Assistants (CNAs) and nurses on both weekdays and weekends. However, these administrative staff members were salaried and did not clock in and out, leading to inaccuracies in the PBJ report. The DON acknowledged that the data submitted for the PBJ report was inaccurate, as it did not reflect the hours worked by the nursing administrative staff in CNA or nursing roles, particularly on weekends. The corporate office was responsible for completing and submitting the PBJ reports, and the Regional Director of Operations confirmed that the data was not submitted correctly. The facility reported a census of 40 residents during this period, and the staffing challenges in November and December required administrative staff to fill in as CNAs and nurses.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to ensure dietary staff adhered to food safety procedures during meal preparation and service, increasing the risk of cross-contamination and foodborne illness. During a dining observation, a dietary aide was seen wearing a T-shirt with multiple holes and a large wet stain, without an apron or clothing protector. This same aide was observed carrying resident drinking glasses with fingers inside the glass, filling them with beverages, and serving them to residents. Additionally, the aide handled dirty dishes and then clean dishes without performing hand hygiene. In the kitchen, a dietary cook was observed preparing hamburger patties and pureeing lunch items without washing hands between tasks. The cook also failed to check the final cooking temperature of the hamburgers before serving them to residents. While working at the steam table, the cook was seen coughing and sneezing into her elbow/upper shoulder area without consistently performing hand hygiene. The dietary manager acknowledged these lapses in food safety practices, noting that the dietary aide often needed reminders to perform hand hygiene.
Failure to Complete and Clarify SNF ABN Forms
Penalty
Summary
The facility failed to ensure that residents or their representatives completed the Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN) and clarified their wishes, affecting two out of three residents reviewed. Resident #10, who had no cognitive impairment, signed the SNF ABN form but did not choose an option for how to proceed with potential out-of-pocket payments for skilled care. The clinical record lacked documentation that the facility asked Resident #10 to choose an option, indicating a failure in the process of obtaining informed consent. Resident #37, who had severe cognitive impairment, had their representative sign the SNF ABN form, choosing option #1 to receive care and have Medicare billed for an official decision on payment. However, the clinical record did not document whether the resident received the care, whether Medicare was billed, or if the facility clarified the accuracy of the option chosen with the representative. The facility's administrator acknowledged the oversight, attributing it to the absence of a social worker and his own involvement in handling the notices without full awareness of the choices made.
Failure to Conduct Background Check Prior to Rehire
Penalty
Summary
The facility failed to complete necessary background checks for a Certified Nursing Assistant (CNA), identified as Staff C, prior to rehire. Staff C's personnel file, with a rehire date of March 11, 2024, lacked documentation of the Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry, and Professional License checks. The Business Office Manager confirmed that the only background check on file was dated October 24, 2023, and acknowledged the oversight. The facility's practice was for the Business Office Manager to conduct background checks for new employees and those returning after an absence of six weeks or more. However, the Administrator stated that a background check should be completed if the gap between employment and rehire exceeds 30 days. Despite this, the facility did not have a specific policy or procedure for pre-employment background checks, only a general abuse prevention policy that required pre-screening for abusive behavior.
Failure to Update PASSR Evaluations for Residents
Penalty
Summary
The facility failed to submit updated Level 2 Preadmission Screening and Resident Review (PASSR) evaluations for two residents following changes in diagnoses or treatment. Resident #40, who has severe cognitive impairment and diagnoses including depression, anxiety, and a psychotic disorder, had medication changes that were not reflected in an updated PASSR. The resident's care plan included the use of high-risk medications such as Lamotrigine, Sertraline, Lorazepam, and Buspirone, but the only documented PASSR was from 2022. The facility's social worker acknowledged the need for an updated PASSR due to medication changes but faced technical issues in completing it. Resident #18, also with severe cognitive impairment, had diagnoses of Non-Alzheimer's Dementia, Depression, and Bipolar Disorder. The resident's most recent PASSR was from 2021, which did not reflect the current mental health diagnoses or the transition to hospice services. The facility's Social Services/Admissions Coordinator confirmed the absence of a recent PASSR and acknowledged the need for an update. The Director of Nursing expected the social services department to complete PASSRs as required, but there was a gap in responsibility during a transition period between staff. The facility's Administrator noted that the completion of a PASSR for residents admitted from another facility was left to the discretion of the Social Services/Admissions Coordinator. However, Resident #18 was admitted with an outdated PASSR from 2021, and the facility lacked a specific policy for PASSR completion. This oversight resulted in the failure to update PASSRs for residents with significant changes in their mental health diagnoses and treatment plans.
Inadequate Catheter and Perineal Care for Resident
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with severe cognitive impairment and an indwelling urinary catheter. The resident, who had diagnoses including obstructive uropathy and hydronephrosis, was observed with the catheter bag hanging uncovered and the tubing touching the floor. During a care session, staff did not perform complete perineal care or catheter care after the resident was incontinent of bowel movement. The staff used the same cloth for cleaning both the anal and perineal areas without changing gloves or performing hand hygiene, contrary to the facility's policy. Additionally, the staff prepared washcloths for care by placing them in the sink, and disposed of water used for care in the sink instead of the toilet, which was against the facility's protocol. The Director of Nursing confirmed that the catheter bag and tubing should not touch the floor, and complete perineal and catheter care should be performed after a bowel movement. The facility's policies on incontinent and catheter care were not followed, leading to the deficiency.
Failure to Provide Recommended Dietary Interventions
Penalty
Summary
The facility failed to provide the recommended dietary interventions for a resident with a history of significant weight loss. The resident, who had severe cognitive impairment and was diagnosed with malnutrition, was supposed to receive ice cream at lunch and supper as part of their nutritional plan. However, during an observation, the resident did not receive ice cream at lunch, despite the dietician's recommendation. Additionally, the facility's documentation lacked details on the amount of nutritional supplement the resident received, as the Medication Administration Record did not specify how much was given or consumed. The resident's care plan included dietary interventions due to potential nutritional problems related to depression and hypertension. Despite these interventions, the facility did not ensure the resident received the prescribed ice cream, and there was inadequate documentation of the nutritional supplement intake. The facility's policy required monitoring of residents experiencing significant weight changes, but the lack of documentation and failure to provide the recommended dietary items indicate a deficiency in following these protocols.
Failure to Complete and Submit VA Forms for Residents
Penalty
Summary
The facility failed to offer and complete the Veterans Administration (VA) form for one resident and did not file the necessary paperwork for eligibility for another resident. Specifically, Resident #30, who was admitted on 11/28/2023, did not have the VA paperwork completed, as confirmed by the facility's Action Summary and the absence of the documentation. Additionally, Resident #22, admitted on 8/1/2023, did not have their eligibility paperwork submitted to the VA. The Administrator acknowledged the missing documentation for Resident #30 and the failure to submit the paperwork for Resident #22, noting that the Social Worker is responsible for completing and submitting the VA form upon admission.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to provide care in a manner that prevents infection for two residents with severe cognitive impairment. Resident #30, who has a history of stroke and relies on staff for toileting hygiene, was observed during care where staff used improper techniques. Staff used washcloths wetted in the sink for perineal care, placed soiled washcloths on the floor, and did not change gloves between cleaning different areas of the body. This improper handling of soiled materials and lack of glove changes during care increased the risk of infection. Resident #37, also with severe cognitive impairment and a diagnosis of obstructive uropathy, was not provided complete perineal or catheter care after a bowel movement. Staff used washcloths wetted in the sink and did not change gloves between cleaning the anal and perineal areas. Additionally, water used for care was improperly disposed of in the sink instead of the toilet. These actions were contrary to the facility's policies on incontinent care and standard precautions, which emphasize preventing contamination and the transfer of microorganisms.
Failure to Identify and Treat Pressure Ulcers and Skin Impairments
Penalty
Summary
The facility failed to identify and treat pressure ulcers and other skin impairments for a resident, leading to a deficiency in providing appropriate pressure ulcer care. The resident, who had a history of pressure wounds and was at risk for developing new ones, was found to have multiple untreated pressure ulcers and skin impairments upon admission to the hospital. These included a healing pressure ulcer on the right hip, unstageable pressure ulcers on both heels, and venous insufficiency ulcers on both feet. Additionally, the resident had moisture-associated skin damage in the groin area and other skin issues that were not documented or treated by the facility. The clinical records and staff interviews revealed that the facility did not conduct regular and thorough skin assessments for the resident. The last documented skin observation was on 3/21/24, and subsequent evaluations were either incomplete or missing. The wound care specialist's follow-up evaluation on 3/28/24 also lacked documentation of the resident's pressure wounds and other skin impairments. Despite the presence of skin issues noted by CNAs during bathing, these concerns were not adequately reported or addressed by the nursing staff. Interviews with staff members, including CNAs and the DON, indicated a lack of awareness and documentation regarding the resident's skin conditions. The DON and other staff members acknowledged the presence of dry, flaky skin and scabbed areas on the resident's feet but did not recall any pressure ulcers on the heels or other significant skin impairments. The facility's policies on skin evaluation and wound management were not followed, resulting in a failure to provide evidence-based treatments and consistent documentation of the resident's skin condition and treatment needs.
Failure to Ensure Required Members Attend QAA Meetings
Penalty
Summary
The facility failed to ensure all required members attended the quarterly Quality Assessment and Assurance (QAA) meetings. Specifically, the Director of Nursing (DON)/Infection Preventionist (IP) was absent for 2 of the 4 quarterly meetings reviewed. The review of the QAPI meeting sign-in sheets from April 2023 to March 2024 revealed that the DON/IP attended only the meetings in April 2023 and March 2024. This was confirmed by the Administrator, who acknowledged the absence of the DON/IP's signatures for the other two meetings. The facility's policy, last reviewed in August 2020, mandates that the QAA team includes the Administrator, DON, Medical Director, IP, and other key staff members, and that they meet monthly.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
