Algona Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Algona, Iowa.
- Location
- 2221 East Mcgregor Street, Algona, Iowa 50511
- CMS Provider Number
- 165504
- Inspections on file
- 21
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Algona Manor Care Center during CMS and state inspections, most recent first.
A CNA was hired without a documented background check, as required by facility policy and state regulations. The Administrator confirmed the omission, noting it was missed due to a new office manager at the time of hire.
A resident with moderate cognitive impairment and multiple psychiatric diagnoses received a new diagnosis of delusions, but the facility did not complete a new PASRR Level I screening as required. The Social Worker, responsible for PASRRs, confirmed the oversight during interview.
A resident with Non-Alzheimer's Dementia, dependent on staff for toileting, did not receive appropriate perineal care. During an observation, two CNAs assisted the resident, but one failed to cleanse the resident anteriorly, contrary to the Nurse Aide Skills Checklist directives. This deficiency was confirmed by the CNA involved.
The facility failed to store and label food items according to professional standards, as observed during a kitchen tour. Various opened food items in the refrigerator, freezer, and dry storage were not labeled with dates, contrary to facility policy. The Dietary Manager confirmed the expectation for staff to label and date items when opened, with leftover food considered good for seven days.
A resident with COPD and other health conditions was prescribed azithromycin for prophylactic antibiotic therapy. Despite physician orders and pharmacy consultation, the resident's care plan was not updated to include this medication, its potential side effects, or monitoring requirements. The DON acknowledged the omission, which was contrary to the facility's policy on care plan development.
A facility failed to provide necessary assessments and interventions for a resident with a UTI, compromising their well-being. The resident, with severely impaired cognition, had frequent UTIs and was treated with antibiotics multiple times. The care plan did not address UTI risks or monitoring. During the latest UTI treatment, the facility did not document urinary assessments, vital signs, or adverse drug effects. The DON expected documentation of vital signs and symptoms during antibiotic treatment, but no such documentation was found, and the facility lacked relevant policies.
A resident at high risk for pressure ulcers developed a stage 1 ulcer on the left heel due to the facility's failure to update the care plan with new interventions. Despite existing measures like pressure-reducing devices, the Treatment Administration Record lacked documentation of treatment orders for the ulcer. Observations showed inconsistent use of pressure-relieving devices, and the DON confirmed the treatment was not properly documented.
A resident with multiple health conditions, including amputations, did not receive proper infection control during a dressing change. The RN failed to change gloves and perform hand hygiene between handling supplies and cleansing the wound, contrary to the facility's policy. The DON confirmed the expectation for staff to follow proper procedures.
A facility failed to follow its antibiotic stewardship program for a resident prescribed Methenamine for urinary tract infections without an end date. The clinical records lacked documentation of monitoring the long-term use of this antibiotic. The IP stated that the facility reviews long-term antibiotic use annually, and the Pharmacy Consultant noted the issue was addressed earlier but lacked follow-up. The facility's policy aims to ensure antibiotics are used only when necessary, which was not adhered to in this case.
The facility failed to answer call lights within the required 15 minutes for a resident, who reported waiting 30 minutes or longer, causing her to feel neglected and experience pain. Staff interviews and Resident Council Minutes confirmed the issue, citing operational inconsistencies during the second shift.
Failure to Complete Required Background Check for CNA
Penalty
Summary
The facility failed to complete a required background check for one of six current employees reviewed, specifically a Certified Nurse Aide (CNA) who was hired on 9/20/24. Review of the CNA's employee file showed no documentation of a background check. During an interview, the Administrator confirmed that the background check was not completed, attributing the oversight to the office manager, who had just started around the time of the CNA's hire. The facility's policy, dated October 2022, requires a criminal record check prior to hire in accordance with 481 Iowa Administrative Code 58.11(3).
Failure to Complete New PASRR Following New Diagnosis
Penalty
Summary
The facility failed to complete a new Preadmission Screening and Resident Review (PASRR) Level I for a resident who received a new diagnosis of delusions on 2/27/25. Clinical record review showed that the resident had a history of moderate cognitive impairment, as indicated by a BIMS score of 12, and diagnoses including anxiety, psychotic disorder (other than schizophrenia), and malnutrition. The existing PASRR Level I screening, dated 8/12/24, was completed at the hospital prior to admission and indicated that no Level II was required. Despite the new diagnosis, the facility did not submit a new PASRR as required. During staff interview, the Social Worker confirmed responsibility for completing PASRRs when new diagnoses or medications are identified but was unsure why the new PASRR was not completed in this instance.
Inadequate Perineal Care for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide appropriate perineal care for a resident diagnosed with Non-Alzheimer's Dementia, who was cognitively impaired with a BIMS score of 8 out of 15. The resident was dependent on staff for toilet transfers and toileting and was frequently incontinent of bowels and bladder. The care plan for the resident required assistance with activities of daily living, including toileting upon rising, before or after activities, and at bedtime, as well as assistance with incontinent care as needed. During an observation, two CNAs were assisting the resident with toileting. Staff A confirmed the resident was incontinent and removed the soiled brief. However, Staff A failed to cleanse the resident anteriorly after cleaning the mid gluteal region and bilateral buttocks. This was confirmed by Staff A during an interview. The Nurse Aide Skills Checklist from 2012 directed staff to wash and rinse the abdomen and anterior thighs, and for women, to gently separate the labia and wash from front to back, which was not followed in this instance.
Failure to Label and Date Opened Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food storage and labeling, as observed during a kitchen tour. Various food items in the kitchen's refrigerator were found to be opened and not labeled with dates, including American cheese slices, ham salad, smoked ham, Swiss cheese, tomato juice, butter blend spread, cookies, salsa, Worcestershire sauce, ketchup, tartar sauce, mayonnaise, Hershey syrup, Dijon mustard, honey mustard, chocolate milk, 2% milk, half & half cream, almond milk, heavy whipping cream, cucumber salad, and hot dogs. Additionally, items in the kitchen's freezer, such as fish sticks, omelets, and chicken strips, were also not labeled with dates after opening, with the fish sticks showing signs of freezer burn. In the dry storage area, several items were found open and not dated, including instant banana pudding mix, dry gelatin mix, chocolate pudding mixture, and Raisin Bran cereal. The Dietary Manager confirmed that the expectation was for dietary staff to label and date items when opened, and that leftover food was considered good for seven days after opening. The facility's policy required that once a product was opened, it should be dated with the date of opening, and food should be stored, prepared, distributed, and served according to professional standards for food service safety.
Failure to Revise Care Plan for Antibiotic Therapy
Penalty
Summary
The facility failed to revise the care plan for a resident receiving prophylactic antibiotic therapy. The resident, who had intact cognition, was diagnosed with coronary artery disease, hypertension, chronic obstructive pulmonary disease (COPD), and pulmonary embolism. The care plan, last revised on 7/24/24, included the need for assistance with activities of daily living due to COPD and the use of supplemental oxygen. However, it did not address the antibiotic medication, azithromycin, prescribed for COPD exacerbation, pneumonia, and rehospitalization, nor did it include potential side effects or monitoring requirements for this high-risk medication. A physician order dated 5/15/24 directed the administration of azithromycin 250 mg on specific days, and a pharmacy consulting form dated 6/19/24 confirmed the continuation of this order for 365 days. Despite these directives, the care plan was not updated to reflect the antibiotic therapy. The Director of Nursing acknowledged the omission and stated that the antibiotic should have been included in the care plan. The facility's policy on care plan development requires comprehensive plans to include approaches, goals, and interventions reflecting the resident's preferences and choices, and to be reviewed periodically for necessary updates.
Failure to Monitor and Document UTI Treatment
Penalty
Summary
The facility failed to provide necessary assessment and interventions for a resident diagnosed with a urinary tract infection (UTI), compromising the resident's highest practical physical well-being. The resident, who had severely impaired cognition and was dependent on staff for toileting, had a history of frequent UTIs and was treated with antibiotics multiple times from January to July 2024. Despite this, the resident's care plan did not address the risk of UTIs, nor did it include monitoring for signs and symptoms or interventions to reduce the risk. During the resident's most recent UTI treatment in July 2024, the facility did not document urinary assessments, routine vital signs, or any adverse drug effects while the resident was on antibiotic therapy. The Director of Nursing expected staff to document full sets of vital signs and monitor urinary symptoms and signs of infection during the first three days of antibiotic treatment and on the last day to assess improvement. However, there was no documentation of these assessments, and the facility lacked policies on what to document or monitor when a resident was on antibiotics.
Failure to Prevent and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to prevent a stage 1 pressure ulcer in a resident, identified as being at high risk for pressure ulcers due to conditions such as malnutrition, diabetes, dementia, and Parkinson's disease. The resident's care plan included interventions like pressure-reducing cushions and mattresses, weekly skin assessments, and the use of heel protectors, which the resident sometimes refused. Despite these measures, the care plan did not include any new interventions after the discovery of a stage 1 pressure ulcer on the resident's left heel. The facility's documentation revealed inconsistencies in the treatment of the pressure ulcer. The Treatment Administration Record (TAR) for July and August 2024 did not show any orders for treatment of the left heel, despite the presence of a pressure ulcer. Observations noted that the resident was not always using pressure-relieving devices, and there was no documentation of the resident's refusal to wear heel boots, which was reported verbally by staff. Interviews with the Director of Nursing (DON) confirmed that the treatment for the pressure ulcer was not entered into the treatment sheet as required. The DON acknowledged that the treatment should have been documented and that there was no alternative intervention in place before the pressure ulcer was discovered. The facility's policy emphasized the importance of timely intervention and care plan revision, which was not adhered to in this case.
Inadequate Hand Hygiene and Glove Use During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, specifically in hand hygiene and glove use, during a dressing change for a resident. The resident, who had intact cognition and required assistance for mobility and toileting, had a history of multiple health conditions including diabetes mellitus, multidrug-resistant organism, and amputations. The resident's care plan included specific instructions for wound care on the left great toe amputation site, which was not followed correctly by the staff. During the dressing change, the RN did not change gloves or perform hand hygiene between handling supplies and cleansing the wound, which is against the facility's standard precautions policy. The RN acknowledged the failure to adhere to proper hand hygiene and glove-changing protocols. The Director of Nursing confirmed the expectation for staff to change gloves and perform hand hygiene between dirty and clean procedures, as outlined in the facility's policy.
Failure to Monitor Long-Term Antibiotic Use
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship program, which is designed to monitor and regulate the use of antibiotics. This deficiency was identified in the case of a resident who was prescribed Methenamine 1 Gram, to be taken twice daily as a prophylactic measure for urinary tract infections, with no specified end date. The clinical records did not show any documentation of monitoring the long-term use of this antibiotic. During an interview, the Infection Preventionist (IP) mentioned that the facility has a system to monitor long-term antibiotic use, but it is generally reviewed only once a year. Additionally, the Pharmacy Consultant confirmed that the prophylactic antibiotic use was addressed in January 2023 but expressed a desire for the IP to have followed up on it. The facility's policy on Antibiotic Stewardship, effective since December 2017, aims to ensure antibiotics are administered only when necessary and in collaboration with the consulting pharmacy and provider, but this was not followed in this instance.
Failure to Answer Call Lights Timely
Penalty
Summary
The facility failed to answer resident call lights within the professional standard of 15 minutes for one of the three residents reviewed. Resident #3 reported waiting for 30 minutes or longer for her call light to be answered, causing her to feel neglected and experience pain when left in the bathroom for extended periods. Staff interviews confirmed that call lights were often not answered within the required time frame, particularly during the second shift due to various operational inconsistencies such as meal times, staff breaks, and shift changes. Resident Council Minutes from January, February, and March also documented residents' concerns about call light wait times. The facility's policy mandates that all call lights should be answered within 15 minutes, which was not adhered to in this case.
Latest citations in Iowa
A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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