Arbor Springs Of West Des Moines L L C
Inspection history, citations, penalties and survey trends for this long-term care facility in West Des Moines, Iowa.
- Location
- 7951 E P True Parkway, West Des Moines, Iowa 50266
- CMS Provider Number
- 165548
- Inspections on file
- 18
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Arbor Springs Of West Des Moines L L C during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, and depression had documented worsening behaviors, expressed suicidal thoughts, and engaged in self-harm with a screwdriver, as recorded in progress notes. Despite these events and existing policy requiring care plan review and revision with significant changes in condition, the comprehensive care plan and Kardex lacked any focus, goals, or interventions addressing suicidal ideation or self-harm. The DON and Administrator acknowledged that the care plan was not updated after the resident’s suicidal statements and self-harm incident.
A resident with severe cognitive impairment, dementia, and depression expressed suicidal intent, used a screwdriver to inflict a hand injury, and refused to relinquish the tool while stating he wanted to kill himself. A CNA notified an LPN, who confirmed the self-harm and suicidal statements and called the resident’s family, but did not notify management or the DON and did not initiate 15-minute checks or remove hazardous items that night. Oncoming staff were not fully informed of the event, no structured close monitoring was implemented overnight, and hazardous items remained in the resident’s room until the following day. The DON and Administrator later acknowledged there was no specific policy on self-harm or suicidal ideation and that expected safety measures were delayed, resulting in a failure to ensure adequate supervision and a hazard-free environment.
A resident with severe cognitive impairment and a history of weight loss was served a regular diet meal with large, tough meat chunks instead of the prescribed mechanically altered diet with ground meats. Staff identified the inconsistency during feeding, and interviews revealed confusion over dietary orders contributed to the error, as the meal did not meet the requirements for a mechanically soft diet.
A Certified Medication Aide did not complete the required dependent adult abuse training within six months of hire, and there was no documentation of annual training. The DON confirmed the lack of training records, which is not in accordance with facility policy requiring timely abuse prevention education for staff.
A resident with a history of Alzheimer's, peripheral vascular disease, and recent surgery was admitted with multiple skin concerns, including a stasis ulcer and bruising. Staff failed to consistently document follow-up skin assessments, measurements, and wound details in the EHR, and did not always complete required incident reports or follow facility protocols for new skin issues. Observations and interviews confirmed gaps in documentation and assessment, despite the resident's ongoing skin problems and discomfort.
A resident with Alzheimer's disease and muscle weakness, dependent on staff for wheelchair mobility, was repeatedly observed being pushed by a CNA with one or both feet dragging on the floor instead of being placed on the wheelchair foot pedals. Multiple staff interviews confirmed this practice was against facility protocol, and the DON stated that residents' feet should always be on the pedals during wheelchair movement. The facility could not provide a written policy on wheelchair locomotion.
Two residents were involved in medication errors when Certified Medication Aides crushed extended-release (ER) tablets—Metoprolol ER and Potassium Chloride ER—contrary to pharmacy guidance and manufacturer recommendations. These errors resulted in a medication error rate of 6.67%, exceeding the acceptable threshold. The facility's medication administration policy lacked specific instructions regarding the crushing of ER medications.
Staff did not follow Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer, as the care plan lacked EBP directives, there was no EBP signage, and the LPN did not wear a gown during wound care. Staff interviews revealed inconsistent understanding of EBP requirements, and facility policies did not adequately address EBP utilization.
A resident with a history of falls and severe cognitive impairment was lowered to the floor by staff and subsequently experienced significant pain. Despite vocal complaints and a care plan indicating fall risk, the LPN did not assess the resident, and the ADON delayed assessment. The DON obtained an order for pain medication but did not ensure its administration. An x-ray later revealed a hip fracture requiring surgery. Staff interviews highlighted communication failures and policy non-compliance in managing the resident's condition.
A facility failed to conduct required post-fall neurological assessments for three residents with severe cognitive impairments who experienced unwitnessed falls. Despite care plans indicating fall risks and protocols for neurological assessments, documentation was incomplete, with missing assessments in the EHR. Staff interviews confirmed the protocol requirements, but the Director of Nursing acknowledged the lack of completed assessments.
The facility failed to have an RN on duty for at least 8 consecutive hours a day, as required by CMS regulations. This was confirmed through CMS PBJ data and facility documents, revealing a 48-hour period without RN coverage. Staff interviews indicated awareness of the requirement, but the facility's policy did not explicitly mandate RN presence for the required hours.
A facility failed to notify the LTC ombudsman of a resident's transfer to an acute care hospital. The resident's transfer was not included in the February 2024 report due to an issue with the admission and discharge report generated by Point Click Care (PCC). Despite verifying the correct transfer dates in the EHR, the resident's name was missing from the report. The Administrator contacted IT to investigate the issue, and it was noted that the facility lacks a policy for ombudsman notification, relying on a monthly spreadsheet procedure.
A resident with dementia and diabetes, at risk for pressure ulcers, did not receive consistent skin assessments as required by their care plan. The facility's records showed incomplete documentation, with missing wound measurements and additional unassessed wounds. Staff interviews revealed inconsistencies in the documentation process, and the facility's electronic health record lacked comprehensive assessments.
A resident with Alzheimer's and dementia did not receive proper incontinence care, leading to a deficiency. Two CNAs failed to follow infection control practices, such as changing gloves when contaminated and cleansing from front to back. The DON confirmed the expected procedures, which were not adhered to during the observed care.
Failure to Update Care Plan for Suicidal Ideation and Self-Harm
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan to address suicidal ideation and self-harm behaviors, despite clear documentation of such behaviors in the clinical record. The resident had severe cognitive impairment, with a BIMS score of 2, and diagnoses including non-Alzheimer’s dementia and depression. The MDS documented that the resident’s behavior status had worsened compared to the prior assessment and that the resident sometimes felt lonely or isolated. Progress notes showed that on one occasion the resident became upset about being unable to leave, stated on a speakerphone call with family that he would kill himself, and was subsequently placed on 15-minute checks after the PCP was notified. The PCP advised continuing 15-minute checks and considering psychiatric follow-up for depression if the family allowed. A later progress note documented that at bedtime the resident picked up a screwdriver and inflicted a small skin tear on the back of his left hand, stating he wanted to kill himself, refused to relinquish the screwdriver, and threatened to harm anyone who tried to take it, while staff attempted to deescalate the situation. Despite these documented suicidal statements, ideations, and a self-harm incident, the resident’s care plan did not include a focus area, goals, or interventions related to suicidal ideation or self-harm. The Kardex used by staff on the household also lacked any information or interventions related to these behaviors. During interviews, the DON and the Administrator both acknowledged that the care plan was not updated after the suicidal statements and self-harm incident, even though facility policy required the comprehensive care plan to be reviewed and revised with significant changes in condition and as needed.
Failure to Implement Immediate Safety Measures After Resident’s Suicidal Statements and Self-Harm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain an environment free of potential hazards after a resident made suicidal statements and engaged in self-harm. The resident had severe cognitive impairment with a BIMS score of 2, and diagnoses including non-Alzheimer’s dementia and depression. The MDS documented that the resident’s behavior status had worsened compared to the prior assessment and that the resident sometimes felt lonely or isolated. The care plan noted antidepressant use for depression and directed staff to monitor and report adverse reactions such as social isolation and suicidal thoughts. On the evening in question, after dinner, staff observed the resident with a small screwdriver in hand and a cut on the back of his left hand. The resident stated he wanted to kill himself and refused to relinquish the screwdriver, threatening to harm anyone who tried to take it. A CNA notified the floor nurse (an LPN), who came to the unit and confirmed the resident’s suicidal statements and self-inflicted injury. The LPN contacted the resident’s family, who arrived and were eventually able to get the screwdriver from the resident and help calm him. During this time, the resident remained in the common area with the screwdriver while staff attempted to deescalate the situation. The family member later reported that when she left around late evening, the resident was not on one-to-one observation and she was not informed of any specific safety measures in place. Multiple staff interviews and record reviews showed that no immediate safety interventions, such as initiating 15-minute checks or removing hazardous items from the resident’s room, were implemented the night of the incident. The LPN who managed the event did not notify management or the DON on call, and acknowledged that no safety measures were put in place until the following day. The oncoming night-shift LPN was told only that the resident had been upset and made a suicidal statement, and was not informed about the screwdriver or self-inflicted injury. The overnight CNA was not instructed to perform 15-minute checks and instead checked on the resident only as often as she could. Staff working the following morning, including the day-shift LPN and the social worker, learned of the suicidal incident only by reading the 24- or 72-hour reports, and both reported that no safety precautions were in place when they started their shifts. The DON later confirmed she was not informed until the next morning and acknowledged there was a delay in implementing protective steps, and both the DON and Administrator stated the facility did not have a policy on self-harm or suicidal ideation, relying instead on “standard practice of care.” The deficiency is further supported by documentation that 15-minute checks were not started until the late morning of the day after the incident, despite the resident’s explicit suicidal statements and self-harm the previous evening. Staff interviews indicated that in a prior episode months earlier, when the resident made verbal comments about wanting to hurt himself, 15-minute checks had been initiated immediately, contrasting with the lack of timely action in this event. The delay in removing hazardous items from the resident’s room and the absence of immediate, structured monitoring following the suicidal statements and self-inflicted injury demonstrate that the facility did not ensure an environment free from accident hazards or provide adequate supervision to prevent further accidents for this resident. The Administrator and DON both acknowledged that there was no specific facility policy addressing suicidal ideation or self-harm, and that staff were expected to follow a general standard practice that included immediate notification of management, physician contact, initiation of 15-minute checks, and removal of potentially harmful items. However, these expected steps were not carried out at the time of the incident. The lack of timely communication among nursing staff, failure to promptly notify the DON, and failure to implement enhanced supervision and environmental safety measures after the resident’s suicidal statements and self-harm directly contributed to the deficiency.
Failure to Provide Prescribed Mechanically Altered Diet
Penalty
Summary
A deficiency occurred when a resident with significant cognitive impairment, a history of weight loss, and multiple diagnoses including GERD and seizure disorder, was not provided with the prescribed mechanically altered diet. The resident's care plan and diet card specified a mechanically soft diet with ground meats, but during a direct observation, the resident was served a regular diet soup containing large, tough chunks of beef and vegetables. Staff feeding the resident noticed the inconsistency, as the meat could not be easily cut or mashed, and confirmed it was not appropriate for the resident's ordered diet. Interviews with staff revealed that dietary staff were responsible for plating food according to diet cards, while CNAs served the food. Both the CNA and dietary manager confirmed the meal served did not meet the resident's dietary requirements. The dietary manager attributed the error to confusion stemming from a previous hospice provider's order, which had allowed for pleasure feedings of normal textured foods, whereas the current order required only mechanically altered foods. Facility policy required mechanically soft diets to include moist, ground meats and soft foods, which was not followed in this instance.
Failure to Complete Required Dependent Adult Abuse Training for Staff
Penalty
Summary
The facility failed to ensure that a Certified Medication Aide completed dependent adult abuse training within six months of hire, as required by facility policy. Review of the employee file for this staff member showed no documentation of the required training, either within the initial six-month period or annually thereafter. During an interview, the Director of Nursing confirmed the absence of this documentation. The facility's policy mandates that employees complete two hours of training on identification and reporting of dependent adult abuse within six months of employment, and that all nurse aides receive initial and annual abuse prevention training.
Failure to Document and Follow Up on Skin Assessments
Penalty
Summary
The facility failed to document follow-up skin assessments for a resident with known skin concerns, including a stasis ulcer, skin tear, and bruising. The resident, who had a history of left femur fracture, Alzheimer's Disease, and peripheral vascular disease, was identified as being at risk for pressure ulcers. Upon admission, the resident had a stasis ulcer on the right ankle, a surgical incision to the left thigh, and a skin tear on the left elbow, but the initial skin observation tool did not include wound measurements. Subsequent skin and wound evaluations recorded limited measurements and lacked details such as drainage, odor, and wound appearance. There was also a gap in documentation of skin assessments for the right ankle ulcer between early and late May, and new skin concerns such as bruises and a skin tear were not fully documented or measured. Staff interviews revealed inconsistent practices regarding skin assessments and documentation. The DON acknowledged that weekly skin assessments were not consistently completed or documented in the electronic health record (EHR), and that incident reports were not always filled out when new skin concerns were identified. Nursing staff described procedures for reporting and assessing skin issues, but there were discrepancies in how and where assessments were documented. One LPN reported being unable to document or photograph bruises due to technical issues, and another staff member indicated that nothing in the EHR flagged the need for attention to the resident's skin concerns. Observations confirmed the presence of unreported or undocumented bruises and wounds on the resident, including a large dark purple bruise on the forearm and scabs on the arm. The resident expressed discomfort during care and indicated that certain areas were painful. The facility's policy required the use of a communication form and thorough assessment for any change in condition, including new skin issues, but these protocols were not consistently followed, resulting in incomplete documentation and follow-up of the resident's skin concerns.
Failure to Ensure Safe Wheelchair Locomotion
Penalty
Summary
Staff failed to ensure safe wheelchair locomotion for a resident diagnosed with Alzheimer's disease and muscle weakness, who was dependent on staff for mobility. Multiple direct observations showed a certified nurse aide (CNA) pushing the resident in a wheelchair without both feet properly placed on the foot pedals. The resident's feet were seen dragging on the floor in socks, sometimes erratically kicking, and at one point nearly being run over by the wheelchair wheels. These incidents occurred during transfers between the living room and dining room, and while moving the resident between tables. Interviews with several staff members, including CNAs and a certified medication aide, confirmed that facility protocol requires residents' feet to be elevated on foot pedals during wheelchair movement to prevent injury. Staff acknowledged awareness of the proper procedure and the risks associated with non-compliance, such as falls and abrasions. The Director of Nursing also confirmed the expectation that staff ensure residents' feet are on the foot pedals during wheelchair locomotion. The facility was unable to provide a written policy regarding wheelchair locomotion during the survey.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing of ER Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors out of 30 observed opportunities, resulting in an error rate of 6.67%. In one instance, a resident with a diagnosis of hypertension was prescribed Metoprolol Succinate Extended Release (ER) 25 mg daily. During medication administration, a Certified Medication Aide (CMA) crushed the Metoprolol ER tablet along with other medications and administered the mixture to the resident. The pharmacist later confirmed that ER tablets should not be crushed, as this could result in the resident receiving too much medication at once. In another case, a CMA prepared and crushed a Potassium Chloride ER tablet for a resident, mixing it with other medications. The surveyor intervened before administration, instructing the CMA not to give the crushed medication, as Potassium Chloride ER should not be crushed. The facility's medication administration policy did not provide guidance on which medications should not be crushed, such as extended-release formulations. These actions led to the facility exceeding the acceptable medication error rate.
Failure to Implement Enhanced Barrier Precautions for Resident with Pressure Ulcer
Penalty
Summary
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a Stage 3 pressure ulcer located on the right fourth finger. The resident's care plan, revised to reflect the presence of the pressure area, did not include directives for EBP. During wound care observation, there was no signage indicating EBP in the resident's room, and the LPN performing wound care did not wear a gown as required by EBP protocols. Interviews with staff revealed inconsistent understanding and application of EBP, with some staff unaware that wounds required EBP and others acknowledging that wounds, catheters, and MDROs should be included. The DON confirmed that the resident should have been under EBP but was not. Review of facility policies showed that the infection control program did not mention EBP utilization, and the EBP policy itself specified that EBP should be used for residents with wounds during high-contact care activities, such as wound care, with gown and gloves required. The CDC guidance referenced also directs EBP implementation for residents with wounds or indwelling devices during high-contact care, regardless of MDRO status.
Failure to Assess and Manage Resident's Pain After Fall
Penalty
Summary
The facility failed to provide a thorough assessment and timely intervention for a resident who was lowered to the floor by staff. The resident, who had a history of falls and severe cognitive impairment, was in pain after the incident, but the LPN did not complete a thorough assessment. The ADON was notified of the resident's pain but did not assess the resident until several hours later, and the DON obtained an order for pain medication but failed to ensure it was administered. An x-ray later revealed a displaced hip fracture requiring surgical intervention. The resident's care plan indicated they were a wander and fall risk, requiring moderate assistance with care and ambulation. Despite vocal complaints of pain, the resident's pain management was inadequate, with no PRN pain medications administered on certain days. The progress notes documented various instances of the resident's pain and the lack of effective pain management, including the discontinuation of Oxycodone due to side effects and the failure to administer it when ordered. Interviews with staff revealed a lack of communication and follow-through regarding the resident's condition. The CNA reported the resident's pain to the LPN, who did not assess the resident or complete an incident report. The ADON and DON were informed of the resident's pain but delayed in assessing and addressing it. The facility's policy on fall assessment was not followed, as the charge nurse did not assess the resident immediately after the fall, and the physician was not notified promptly. This series of inactions and miscommunications led to the resident's delayed diagnosis and treatment of a hip fracture.
Failure to Conduct Post-Fall Assessments
Penalty
Summary
The facility failed to provide adequate post-fall assessments and interventions for three residents who experienced unwitnessed falls. Resident #1, with severe cognitive impairment due to Alzheimer's Disease and depression, had an unwitnessed fall on 10/19/24. Although the resident's care plan indicated a risk for falls and directed staff to follow the facility's fall protocol, the electronic health record (EHR) showed only 12 of the 14 required follow-up neurological assessments were completed. No further follow-up assessments were documented in the progress notes. Resident #2, also with severe cognitive impairment and multiple diagnoses including Non-Alzheimer's Dementia and diabetes, fell on 9/27/24. The care plan highlighted the resident's fall risk due to confusion and balance issues. Despite this, the EHR documented only 3 of the 14 required follow-up neurological assessments. The resident refused an assessment at one point, and a subsequent assessment lacked vital signs documentation. Resident #3, with severe cognitive impairment and a history of falls, experienced an unwitnessed fall on 11/12/24. The care plan noted the resident's fall risk due to confusion. The EHR showed only 7 of the 14 required follow-up neurological assessments were completed. Staff interviews confirmed the protocol for unwitnessed falls required neurological assessments, but documentation was incomplete. The Director of Nursing acknowledged the lack of completed assessments and stated that neurological assessments were documented only in the EHR, not in hard charts.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to maintain a Registered Nurse (RN) on duty for at least 8 consecutive hours a day, as required by CMS regulations. This deficiency was identified through a review of the CMS Payroll Based Journal (PBJ) data, facility documents, and staff interviews. The facility, which reported a census of 51, did not have an RN present for a 48-hour period from November 4, 2023, to the end of November 5, 2023. The staffing schedule provided by the Administrator confirmed the absence of an RN during this period. Additionally, the facility's assessment, last updated in December 2023, did not specify daily staffing requirements. Interviews with staff revealed that the facility informs staff if there is no RN on duty, and CNAs inquire about the nurse in charge when they start their shifts. The Director of Nursing (DON) acknowledged the requirement for an RN to be present for 8 consecutive hours daily and stated that she and the Assistant Director of Nursing (ADON) have alternating on-call schedules to ensure coverage. However, she did not recall the specific period of non-compliance. The Administrator confirmed via email that the facility did not have RN coverage on the specified dates and that their scheduling policy did not explicitly require an RN to be on the premises for 8 consecutive hours daily.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to notify the long-term care ombudsman regarding a resident's transfer to an acute care hospital. The clinical record review and staff interviews revealed that the resident was transferred on February 4, 2024, and returned on February 8, 2024. However, the Notice of Transfer Form to the Long Term Care Ombudsman did not include this resident in the report for February 2024 transfers. The Business Office Manager (BOM) explained that her procedure involves running an admission and discharge report using Point Click Care (PCC), but the resident's name did not appear on the report. Despite verifying the correct transfer dates in the Electronic Health Record (EHR), the issue persisted. The Administrator contacted Information Technology (IT) to investigate potential errors in the report settings. It was also noted that the facility lacks a policy for ombudsman notification, relying instead on a monthly spreadsheet procedure.
Inadequate Documentation of Skin Assessments
Penalty
Summary
The facility failed to document skin assessments for a resident with a history of non-Alzheimer's dementia and diabetes, who was at risk for pressure ulcers and had a Stage 2 pressure ulcer upon admission. The care plan required weekly skin assessments, but the facility's records showed inconsistent documentation of these assessments. Only three out of several assessments included wound measurements, and there were no measurements for a moisture-associated skin disorder on the resident's thigh. Observations revealed additional wounds and redness, indicating a lack of comprehensive and timely skin assessments. Interviews with staff, including a Certified Medication Aide, Registered Nurses, and the Director of Nursing, revealed inconsistencies in the documentation process and a lack of adherence to the facility's policy for weekly skin assessments. The Director of Nursing acknowledged the deficiency in documenting wound measurements and noted that a Performance Improvement Plan was in place. However, the facility's electronic health record lacked comprehensive skin or wound assessments, highlighting a gap in the facility's adherence to its own policies and procedures.
Improper Incontinence Care and Infection Control Practices
Penalty
Summary
The facility failed to provide proper incontinence care to minimize the risk of cross-contamination and urinary tract infections for Resident #26, who has Alzheimer's Disease and dementia, with severely impaired cognition. The resident requires substantial to maximum assistance for toileting hygiene, bed mobility, and transfers. During an observation, two certified nursing assistants (CNAs), Staff A and Staff B, were involved in providing incontinence care to the resident. Staff B placed wet washcloths in a plastic bag by the bed, and both staff members used a mechanical lift to transfer the resident from a Broda chair to the bed. Staff A used a wet washcloth with peri-wash foam to cleanse the resident's lower abdomen and groin, leaving the soiled washcloth between the resident's inner thighs. Staff B removed the soiled brief and used the soiled washcloth to clean the resident's buttocks, failing to change gloves when contaminated. Staff B continued to cleanse the resident's buttocks and gluteal creases, wiping in a downward fashion from back to front, which is against the expected procedure. Staff A instructed Staff B to change gloves, which she did after obtaining additional washcloths. Staff B then applied barrier ointment to the buttocks, again wiping in a downward and circular motion toward the perineum, before removing her gloves. The Director of Nursing (DON) stated that staff are expected to cleanse from front to back during incontinence care and change gloves whenever they become soiled or contaminated. The facility's peri-care skills checklist outlines the proper procedure, which was not followed in this instance, leading to the deficiency.
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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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