Arbor Court
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Pleasant, Iowa.
- Location
- 701 East Mapleleaf Drive, Mount Pleasant, Iowa 52641
- CMS Provider Number
- 165478
- Inspections on file
- 31
- Latest survey
- April 14, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Arbor Court during CMS and state inspections, most recent first.
A facility failed to accurately obtain and implement advanced directives for a resident upon admission. The resident's verbal order for CPR was documented, but no signed document confirmed their wishes for life-sustaining measures. The DON could not locate the resident's IPOST, and although the family communicated a DNR wish, the SSD did not document the contact attempt. The facility's policy on Advanced Directives was not adequately followed.
A resident with severe cognitive impairment and mobility issues was transported in a wheelchair with only one foot pedal, despite staff acknowledging the need for two. The second pedal was broken, and there was no policy for wheelchair transport, leading to a deficiency in ensuring a safe environment.
The facility was cited for a deficiency in the accuracy of MDS assessments, specifically regarding the smoking status of two residents. Despite recent audits, the MDS was inaccurately coded, and the facility lacked a specific MDS policy, relying instead on the CMS Resident Assessment Instrument. The issue was acknowledged by the DON and MDS Coordinator, who planned to submit corrections.
A resident with multiple health conditions, including schizophrenia and diabetes, refused necessary blood draws and experienced a significant change in blood glucose levels. The facility failed to notify the resident's legal guardian of these refusals and changes, despite policy requirements. Interviews with staff revealed a lack of communication and clarity regarding the notification process.
A facility failed to resubmit a PASRR after a resident's mental health diagnoses changed, including major depressive disorder and psychotic disorder. The oversight was identified through observations and staff interviews, revealing a lack of policy and communication during staff transitions. The SSD confirmed the need for a new PASRR, but it was not submitted due to missed communication and absence of auditing procedures.
A facility failed to document post-dialysis assessments for a resident with end-stage renal disease, missing vital signs documentation on multiple occasions. Staff interviews revealed that the assessments were supposed to be recorded on a communication sheet or in the electronic health record, but were absent. The facility lacked a specific dialysis assessment policy, contributing to the oversight.
The facility inaccurately completed MDS assessments for two residents regarding their tobacco use. Despite documentation and interviews confirming their smoking habits, the MDS indicated they did not use tobacco. The DON and MDS Coordinator acknowledged the errors, and the facility lacked a specific MDS policy.
A resident with severe cognitive impairment and a history of wandering eloped from the facility due to unsecured and unalarmed doors. The resident exited through a series of doors, including one with a disengaged lock, and was found outside without shoes. The facility's interventions, such as a Wander Guard, were insufficient, and staff interviews indicated inconsistent alarm monitoring. Additionally, another resident was injured due to improper lifting methods, highlighting the facility's failure to adhere to care plans and maintain a secure environment.
A facility failed to provide a bed hold notice to a resident or their representative upon hospital transfer, as required by guidelines. The resident, who was cognitively intact and had multiple diagnoses, was transferred for treatment without the necessary documentation. Interviews with staff revealed a lack of clarity and adherence to the Bed Hold Policy, with the responsible nurse admitting to not completing the required form.
The facility failed to accurately code medications on the MDS for two residents. One resident, with diagnoses of Atrial Fibrillation and Heart Failure, was not coded for diuretic and hypnotic medications despite having physician orders. Another resident on anticoagulant therapy with Xarelto was not documented on the MDS. Interviews confirmed the omissions, and the facility lacked a specific MDS policy.
A facility failed to update a care plan for a resident identified as a smoker, despite a Smoking Safety Evaluation indicating balance issues. The resident, cognitively intact with a BIMS score of 15, was observed smoking under supervision. The MDS Coordinator was responsible for care plan updates, but the plan lacked necessary interventions per facility policy, such as supervised smoke breaks and secure storage of smoking items.
A housekeeping staff member failed to follow hand hygiene protocols while handling soiled laundry, using bare hands instead of gloves and neglecting to wash hands afterward. The facility's policy requires staff to wear gloves and perform hand hygiene after handling contaminated items, which was not adhered to in this instance.
Failure to Implement Advanced Directives
Penalty
Summary
The facility failed to accurately obtain and implement advanced directives for a resident upon admission. The resident, admitted from a short-term general hospital, had a verbal order for CPR documented in their Order Summary Report. However, there was no signed document in the electronic health record to confirm the resident's wishes for life-sustaining measures. The Director of Nursing (DON) was unable to locate the resident's Iowa Physician Orders for Scope of Treatment (IPOST) in the binder, which is essential for communicating preferences for treatments such as CPR and artificial nutrition. The DON later stated that the resident's family had communicated a wish for Do Not Resuscitate (DNR) status, and an IPOST was completed and faxed to the physician for signature. However, the Social Services Director (SSD) acknowledged that an attempt to contact the resident's family was made but not documented. The facility's policy on Advanced Directives requires providing residents or their representatives with information and instructions regarding their rights to make such directives upon admission, which was not adequately followed in this case.
Failure to Ensure Proper Wheelchair Transport
Penalty
Summary
The facility failed to ensure that a resident's wheelchair was equipped with two foot pedals during transport, which is necessary to prevent accidents. Resident #17, who has severe cognitive impairment and uses a manual wheelchair, was observed being pushed by staff with only one foot pedal attached. This occurred on multiple occasions, with staff members acknowledging the need for two foot pedals but continuing to transport the resident with only one. The resident's medical history includes non-Alzheimer's dementia, hemiplegia or hemiparesis, arthritis, and a hip fracture, which further necessitates proper support during wheelchair transport. Interviews with staff revealed that the second foot pedal was broken, and there was no policy in place for wheelchair transport. Staff members were aware of the broken pedal but continued to transport the resident without addressing the issue. The Director of Nursing confirmed the need for two foot pedals when pushing the resident, especially since the resident could not keep her feet on one pedal. Despite this, the facility did not have a policy to guide staff on proper wheelchair transport, contributing to the deficiency.
Deficiency in MDS Accuracy for Smoking Status
Penalty
Summary
The facility was cited for a deficiency related to the accuracy of assessments, specifically under F641, during a recertification survey. The issue was identified through a review of the facility's CASPER report, which indicated that the facility had previously been cited for the same deficiency in February 2024. During the current survey, it was found that the Minimum Data Set (MDS) Comprehensive Assessments for two residents were inaccurately coded as not using tobacco, despite both residents currently smoking at the facility. This discrepancy was acknowledged by the Director of Nursing and the MDS Coordinator, who admitted the coding error and stated that corrections would be submitted. The Administrator expressed surprise at the coding issue, as she had recently audited the MDS for smoking and believed everything was correctly coded. However, during an interview, it was revealed that the facility did not have a specific MDS policy and relied on the CMS Resident Assessment Instrument (User's Manual) for MDS coding. The Administrator, along with the Regional Director of Operations and the DON, acknowledged that the new MDS Coordinator was aware of the plan of correction from the last survey but had focused more on the care plan versus the MDS for smoking issues. The facility's QAPI policy outlines a process for ensuring care and services meet quality standards, but the deficiency indicates a failure to effectively implement these measures in this instance.
Failure to Notify Guardian of Resident's Medical Refusals and Condition Changes
Penalty
Summary
The facility failed to notify the legal guardian of Resident #7 about laboratory refusals and changes in the resident's condition. Resident #7, who has a history of schizophrenia, diabetes mellitus, stroke, aphasia, hemiplegia, and anxiety disorder, was under the guardianship of an agency as per a court order. Despite the resident's moderate cognitive impairment, the facility did not inform the guardian of the resident's refusal to undergo blood draws for essential tests like the Basic Metabolic Panel (BMP) and A1C, nor did they notify the guardian of a significant change in the resident's blood glucose levels. The clinical records showed multiple instances where Resident #7 refused necessary medical procedures, such as blood draws, without the guardian being informed. On one occasion, the resident refused a BMP draw, and although the resident was educated about the purpose, the refusal persisted, and the guardian was not notified. Similarly, when the resident's blood glucose level spiked to 501, the primary care provider was informed, but the guardian was not. Additionally, the resident sustained a minor injury during a transfer, which was also not communicated to the guardian. Interviews with facility staff, including the Assistant Director of Nursing, Licensed Practical Nurse, and Director of Nursing, revealed a lack of clarity and communication regarding the notification process for Resident #7's guardian. The guardian expressed a desire to be involved in the resident's care and was unaware of the refusals and changes in condition until visiting the facility. The facility's policy required notifying the resident's representative of significant changes, but this was not adhered to in Resident #7's case.
Failure to Resubmit PASRR After Change in Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure the resubmission of a Preadmission Screening and Resident Review (PASRR) after a change in mental health diagnoses for a resident. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was diagnosed with several mental health conditions, including major depressive disorder, anxiety disorder, and psychotic disorder. Despite these changes in diagnoses, the facility did not update the PASRR, which was initially exempted in 2019 when the resident did not meet the criteria for serious mental illness or developmental condition. The deficiency was identified through observations, clinical record reviews, and staff interviews. The Director of Nursing and the Social Services Director (SSD) acknowledged the oversight, with the SSD confirming that a new PASRR should have been submitted following the new diagnoses. The facility lacked a policy for PASRR submission and did not have procedures in place to audit for missing PASRRs. The Administrator noted that the oversight occurred during a staff transition period, and the new diagnoses were not communicated effectively within the team.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete post-dialysis assessments for a resident with end-stage renal disease, who required dialysis services. The resident, identified with moderate cognitive loss, had a care plan that included dialysis sessions three times a week. The facility's records indicated an order for vital signs to be taken before and after dialysis sessions. However, there were multiple instances where post-dialysis vital signs were not documented, specifically on four occasions in October and November 2024. Interviews with staff revealed that the post-dialysis assessments were supposed to be documented on a dialysis communication sheet or in the electronic health record. However, these assessments were missing from both the communication records and the electronic health record for the specified dates. The Director of Nursing acknowledged that if the assessments were not documented, they were likely not performed. The facility did not have a specific dialysis assessment policy in place, which contributed to the oversight in documentation.
Inaccurate MDS Coding for Tobacco Use
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents regarding their tobacco use status. Resident #49, who had a Brief Interview for Mental Status (BIMS) score indicating intact cognition, was documented in the MDS as not utilizing tobacco. However, multiple sources, including a Smoke Safety Evaluation, progress notes, and interviews with the resident and staff, confirmed that Resident #49 was a smoker and regularly participated in smoking breaks. Similarly, Resident #18, with a BIMS score indicating moderate cognitive impairment, was also inaccurately documented in the MDS as not using tobacco. Interviews with the resident and staff confirmed that Resident #18 was a current smoker who smoked in designated areas with supervision. The Director of Nursing (DON) and the MDS Coordinator acknowledged the inaccuracies in the MDS coding for both residents. The DON expressed confusion over the incorrect coding, while the MDS Coordinator admitted the errors and indicated plans to submit corrections. The facility's Administrator noted that a recent audit of the MDS for smoking should have ensured correct coding, but discrepancies were still present. The facility's reliance on the Resident Assessment Instrument (RAI) for MDS coding was mentioned, but no specific MDS policy was in place. The errors were in violation of federal regulations requiring that assessments accurately reflect residents' statuses.
Failure to Prevent Resident Elopement and Injury
Penalty
Summary
The facility failed to prevent the elopement of a severely cognitively impaired resident identified at risk for wandering. The resident, who had a history of paranoid personality disorder, schizophrenia, and vascular dementia, exited the facility through a series of doors that were not properly secured or alarmed. The resident was last seen by staff standing in his doorway before being found outside the facility without shoes. The doors the resident used to exit were not alarmed to alert the nursing home section, and the lock on the door to the assisted living portion of the facility had not reengaged, allowing the resident to exit unnoticed. The resident had a documented history of wandering and agitation, with multiple notes in the clinical record indicating frequent pacing, entering other residents' rooms, and being easily redirected. Despite these behaviors, the resident was not in a locked unit, and the facility's interventions, such as the use of a Wander Guard, were insufficient to prevent the elopement. Staff interviews revealed that the resident was known to wander and that the alarms on the doors were not consistently functioning or monitored, contributing to the resident's ability to leave the facility. Additionally, the facility failed to adhere to the care plan for another resident who was dependent on a mechanical lift. This resident was lifted using a non-mechanical method, resulting in skin tears and bruising. The facility's lack of adherence to care plans and failure to maintain a secure environment for residents at risk of elopement and injury led to the identification of immediate jeopardy to the health and safety of the residents.
Failure to Provide Bed Hold Notice
Penalty
Summary
The facility failed to provide a bed hold notice to a resident or their representative upon transfer to the hospital, as required by state and federal guidelines. Resident #11, who was cognitively intact with a BIMS score of 12 out of 15 and had diagnoses including Coronary Artery Disease, Heart Failure, and Renal Insufficiency, was transferred to the hospital for intravenous antibiotic treatment for a urinary tract infection. Upon review, the clinical record lacked documentation of a bed hold notice being given to the resident or their representative. Interviews with facility staff, including a Registered Nurse (RN), the Administrator, and the Director of Nursing (DON), revealed that the nurse responsible for sending the resident to the hospital should review the Bed Hold Policy with the resident or family within 24 hours of the transfer. However, the RN admitted to never having filled out the bed hold form and was unsure if it should be documented in the electronic medical record. The Administrator and DON confirmed the policy but could not explain why it was not completed for Resident #11, with the DON noting she was on medical leave at the time.
Failure to Accurately Code Medications on MDS
Penalty
Summary
The facility failed to accurately code medications on the Minimum Data Sets (MDS) for two residents, leading to deficiencies in their assessments. Resident #33, who was cognitively intact with a BIMS score of 15, had diagnoses of Atrial Fibrillation, Heart Failure, and Diabetes Mellitus. Despite having physician orders for torsemide, a diuretic, and temazepam, a hypnotic, these medications were not coded on the MDS. Observations and interviews confirmed the resident's use of these medications, yet the Assistant Director of Nursing (ADON) and Director of Nursing (DON) could not explain the omission. Similarly, Resident #38, also cognitively intact with a BIMS score of 15, was on anticoagulant therapy with Xarelto, as indicated in the care plan and physician orders. However, the MDS lacked documentation of this anticoagulant medication. Interviews with the ADON and DON confirmed the resident's use of Xarelto and acknowledged that it should have been coded on the MDS. The facility did not have a specific policy for MDS, relying instead on the guidelines of the RAI Manual.
Failure to Update Care Plan for Smoking Resident
Penalty
Summary
The facility failed to update the care plan for Resident #48 to include smoking as a focus area and necessary interventions to ensure safety. Resident #48, identified as cognitively intact with a BIMS score of 15, has a history of smoking and was observed smoking in the designated area under supervision. Despite a Smoking Safety Evaluation Form indicating Resident #48 as a smoker with balance issues, the care plan last revised did not reflect this information. The resident's smoking habit had been known for at least six months, yet the care plan was not updated accordingly. Interviews with staff revealed that the MDS Coordinator, who recently assumed the role, was responsible for updating care plans. However, any nurse could update them. The facility's smoking policy requires that smoking be addressed in care plans, with interventions such as supervised smoke breaks and secure storage of smoking paraphernalia. Despite these requirements, the care plan for Resident #48 did not include these interventions, indicating a lapse in adherence to the facility's policy.
Failure to Follow Hand Hygiene Protocols in Laundry Handling
Penalty
Summary
The facility failed to adhere to standard hand hygiene precautions for infection control when handling soiled laundry. During an observation, a housekeeping staff member, identified as Staff O, was seen using her bare hands to transfer soiled laundry from a garbage bag into a washing machine without wearing gloves. This incident involved dirty clothing protectors from residents. After handling the soiled laundry, Staff O did not perform hand hygiene, such as washing her hands, before leaving the laundry room. Interviews with the facility's Administrator and the Infection Control and Preventionist revealed that staff are expected to use appropriate personal protective equipment (PPE), including gloves, when handling soiled laundry. The facility's policy mandates hand hygiene before and after glove use and after handling contaminated items. Staff O acknowledged her failure to follow these procedures, admitting she forgot to wear gloves and did not wash her hands before leaving the laundry room. The facility's hand hygiene policy, dated April 28, 2022, outlines the importance of hand hygiene in preventing healthcare-associated infections and specifies when it should be performed.
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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