Aspire Of Gowrie
Inspection history, citations, penalties and survey trends for this long-term care facility in Gowrie, Iowa.
- Location
- 1808 Main Street, Gowrie, Iowa 50543
- CMS Provider Number
- 165344
- Inspections on file
- 23
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aspire Of Gowrie during CMS and state inspections, most recent first.
Staff failed to perform hand hygiene after handling a trash can lid and before preparing and serving a hot beverage to a resident, resulting in potential contamination. Additionally, expired milk was used for meal preparation, and multiple food items in storage were found open, unlabeled, undated, or improperly sealed, contrary to facility policy.
The facility failed to submit accurate PBJ staffing data to CMS, resulting in a report that showed insufficient licensed nursing coverage on multiple dates, despite internal records indicating 24-hour nursing services were provided by the DON and RNs. This discrepancy was linked to a change in management and issues with access to staffing information during the reporting period.
The facility had repeat deficiencies in its QAPI program, comprehensive assessments, psychotropic medication management (including PRN use and gradual dose reduction), and food sanitation practices. Surveyors found inaccurate MDS coding, lack of documentation for non-medical interventions before PRN antipsychotic administration, and improper food handling by staff, including failure to perform hand hygiene and improper glove use.
The facility did not complete required MDS entry and discharge assessments within mandated timeframes for four residents who experienced hospitalizations and returns, with documentation either incomplete or still in progress past deadlines. Staff interviews revealed a misunderstanding of assessment requirements, and affected residents had complex medical conditions and recent hospital stays.
The facility failed to accurately code medications and a UTI on MDS assessments for four residents. Errors included not documenting anticoagulant or antidepressant use when prescribed, incorrectly coding antiplatelet medications as anticoagulants, and omitting a UTI diagnosis despite antibiotic treatment. The DON acknowledged the MDS assessments were coded incorrectly.
A resident on a mechanical soft diet was served a meal that did not follow the approved menu, with substitutions made without full RD consultation. The current menu cycle also lacked RD review and signature, contrary to facility policy requiring menus to be reviewed and approved for nutritional adequacy.
Two residents with severe cognitive impairment experienced changes to high-risk medications without documentation that their representatives were notified or consented, despite facility policy requiring such communication. Staff interviews confirmed the expectation for notification, but clinical records lacked evidence that representatives were informed about the medication changes.
A resident with moderately impaired cognition was found with multiple medication cups containing topical creams at bedside, which he self-applied without a physician's order or documented assessment for self-administration. Staff were unaware of the resident's self-administration, and facility policy requiring assessment and secure storage of medications was not followed.
A resident with multiple psychiatric diagnoses did not receive an annual gradual dose reduction (GDR) for an antidepressant as required, and there was no documentation of behavioral monitoring or nonpharmacological interventions before an increase in antipsychotic medication. The DON confirmed the lack of required documentation and adherence to facility policy.
Two residents reported missing money from their personal belongings, but the facility did not notify DIAL or local law enforcement within the required timeframe. The Administrator and DON were either unaware of the missing money or failed to escalate the report, and the incidents were only reported to the Ombudsman. Facility policy requiring prompt reporting of suspected crimes was not followed.
A resident with severe cognitive impairment and multiple medical conditions was discharged to the hospital on several occasions without being offered or provided a Bed Hold notice, as required by facility policy. The clinical record lacked documentation of the notice, and the resident's representative confirmed it was not received. The Administrator was unable to locate the required documentation.
A resident with impaired cognition and multiple health conditions experienced several falls, but the care plan and CNA Kardex were not updated to reflect new fall interventions after each incident. Staff interviews and record reviews confirmed that required updates were not made, despite facility policy mandating care plan revisions when a resident's condition changes.
A resident with severe cognitive impairment and multiple medical conditions was observed with an indwelling urinary catheter, but the care plan lacked specific instructions for catheter management and the physician orders did not include a diagnosis for the catheter. The resident was repeatedly seen with catheter tubing and the drainage bag touching the floor, contrary to facility policy and DON expectations.
Three residents with respiratory conditions did not receive safe and appropriate respiratory care due to failures in documentation, equipment maintenance, and adherence to physician orders. Observations included undated or improperly stored oxygen and nebulizer tubing, lack of care plan direction for oxygen or CPAP use, and incomplete records for respiratory treatments. Staff were inconsistent in following facility policies for respiratory services, resulting in deficiencies in care.
The facility failed to correct deficiencies in their QAPI program and psychotropic medication documentation. A resident received a PRN psychotropic medication without proper documentation of behaviors and nonpharmacological interventions. The DON and ADM initially confirmed compliance with audits but later acknowledged the lack of documentation. Repeated deficiencies were identified in the QAPI program, accident prevention, unnecessary medication use, and notification of changes.
The facility failed to provide safe transfer techniques for two residents, leading to deficiencies in care. A resident with Alzheimer's and other conditions was transferred with only one staff member instead of the required two, while another resident with severe cognitive impairment was transferred without a gait belt. These actions were contrary to the care plans and facility policies, indicating a breach in safety protocols.
A facility failed to notify the Dietitian of a new admission and did not implement nutritional recommendations for a resident with severe cognitive impairment and multiple health conditions. The Dietitian's recommendations, which included dietary supplements and reweighing, were not communicated to the NP or acted upon, resulting in significant weight loss for the resident.
A facility failed to limit a PRN antipsychotic medication to 14 days and did not document non-medicinal interventions before administering the medication to a resident with Alzheimer's and bipolar disorder. The resident's care plan included strategies to manage aggression, but these were not documented as attempted before medication use. The facility's administrator acknowledged the oversight in protocol adherence.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent wound care for a venous ulcer on the right posterior lower leg. The facility failed to document treatments as ordered by the wound center, and the resident's condition worsened over time. Behavioral issues led to transportation refusals, preventing the resident from attending wound center appointments, and the facility did not ensure consistent in-house care.
The facility failed to correct deficiencies in professional standards, resident safety, QAPI program implementation, and food service practices, as identified in both current and past surveys. The Administrator acknowledged the issues, citing staffing challenges and efforts to improve oversight by reallocating the DON's responsibilities. Despite these efforts, the facility continued to struggle with compliance.
The facility did not comply with food service safety standards. A Cook/Dietary Aide was observed improperly handling apple pie by touching multiple surfaces with gloves and failing to cover the pie during transportation. The Food Service Supervisor confirmed that all food should be covered during transport and gloves should be changed after touching non-food surfaces, as per facility policy.
The facility failed to complete timely MDS assessments for two residents due to a management transition and staffing issues. The DON, who was not trained for the role, was responsible for MDS completion after the previous corporate MDS coordinator left. This led to delays in completing both an admission and an annual MDS assessment, contrary to the facility's policy.
A facility failed to complete a quarterly MDS assessment for a resident within the required timeframe. The last assessment was completed in August, and no subsequent assessment was done by December. The DON, who was not initially responsible for MDS, attempted to manage assessments while working on the floor. The facility plans to clarify roles for MDS completion.
A facility failed to accurately code the MDS assessment for a resident, resulting in a deficiency. The resident was admitted to hospice care, and their antipsychotic medication was discontinued, but the MDS did not reflect these changes. The DON acknowledged the coding errors during an interview.
A resident with no cognitive impairment and multiple diagnoses was discharged without a proper discharge planning process. The facility did not include discharge planning in the resident's care plans, and the clinical record lacked documentation of the resident's transfer wishes and contact participation. The resident was discharged to another facility without a documented transfer form, and the facility failed to communicate effectively with the desired facility.
A facility failed to provide a recapitulation of a resident's stay at discharge, as required by their policy. The resident, with a high BIMS score and a history of brain dysfunction, hemiplegia, stroke, dementia, Parkinson's, and seizures, was discharged to another facility. Documentation noted the resident took all belongings and was transported by a staff member, but lacked the required recapitulation.
A facility failed to provide adequate supervision, resulting in multiple falls for a resident with severe cognitive impairment and altercations involving another resident with aggressive behavior. The facility did not consistently notify families or physicians of incidents, nor did they implement effective interventions to prevent future occurrences.
A facility failed to provide an appropriate clinical rationale for declining a gradual dose reduction (GDR) for a resident's medication regimen. The resident, diagnosed with anxiety, depression, diabetes mellitus, and renal insufficiency, was receiving an antidepressant and an antipsychotic. The facility's assessment was incomplete, and the Psychiatric Subsequent assessment lacked documentation for the continued use of these medications, violating the facility's Medication Regimen Reviews policy.
A facility failed to document non-medical interventions before administering an as-needed antipsychotic to a resident with a history of dementia and aggressive behavior. Despite multiple incidents of aggression, records lacked documentation of non-pharmacological interventions or the effectiveness of the medication. The DON reported interventions like offering food or taking the resident back to his room, but these were not documented.
The facility failed to document the administration of an antipsychotic medication for a resident and did not record a fall for another resident. The MAR lacked the physician's order for the medication, and there was no follow-up documentation on its effects. Additionally, the fall incident was not recorded in the progress notes, and the resident's physician and family were not notified.
A facility failed to maintain a safe environment for a resident with severe cognitive impairment and open wounds. The care plan required enhanced barrier precautions (EBP), but no EBP signage or PPE supplies were observed. During wound care, the DON did not follow infection control protocols, including hand hygiene and gown use. Facility policies on MDRO, EBP, and hand hygiene were not adhered to, leading to a deficiency in infection control practices.
The facility failed to notify and document the physician and family for three residents regarding significant incidents. A resident with severe cognitive impairment experienced two falls without proper notification. Another resident reported verbal abuse by a CNA, but the primary physician was not informed. Additionally, a third resident's family was not notified of a facility-reported incident. These actions were contrary to the facility's policy requirements.
A facility failed to obtain a physician's order for Ready Wraps for a resident, despite instructions from a Lymphedema Clinic. The resident, who required assistance with dressing, did not have the wraps applied on several occasions. The DON acknowledged the omission from the Treatment Administration Records and Care Plan. Facility policy required physician orders for all treatments, but no order was placed for the Ready Wraps.
A facility failed to properly handle and document the destruction of medications for a resident, leading to a deficiency. A nurse admitted to discarding medications without proper documentation, contrary to the facility's policy, which requires detailed records and witness signatures for medication destruction.
The facility was found to have multiple deficiencies in food safety and storage, including unsanitary conditions and improper labeling and dating of food items. Observations revealed a build-up of dirt and debris in the kitchen and basement areas, along with several food items that were not labeled or dated, compromising food service safety standards.
The facility failed to submit accurate staffing data for the CMS PBJ Staffing Data Report, with multiple dates lacking 24-hour licensed nurse coverage. The DON, MDS Coordinator, and agency staff covered shifts, but did not clock in, leading to inaccuracies. The Administrator acknowledged the data did not reflect actual nursing hours worked.
The facility failed to address deficiencies in professional standards, accident prevention, and their QAPI program. Challenges include reliance on agency staffing and the DON's need to work on the floor, hindering her administrative duties.
A facility failed to follow physician orders for a resident requiring supervision during ambulation. Despite a history of falls and a physician's order for supervision when walking long distances, the resident's care plan lacked this information, and the resident continued to ambulate independently.
A resident with a history of repeated falls and cognitive impairments experienced 15 falls over six months due to the facility's failure to conduct a root cause analysis and implement effective interventions. Despite various measures like gripper strips and toileting schedules, the resident continued to fall, indicating inadequate supervision and intervention.
A resident with a history of constipation and bowel incontinence was hospitalized due to fecal impaction after the LTC facility failed to provide appropriate bowel management and physician notifications. Despite the resident's refusal of interventions like suppositories and enemas, the care plan lacked specific directions for managing bowel patterns. Progress notes showed gaps in documentation and communication, with no bowel assessments or physician notifications over several months, even as the resident experienced discomfort and abdominal pain. The facility's incontinence management policy was not effectively implemented, leading to a serious health event.
Failure to Maintain Sanitary Food Service and Proper Food Storage
Penalty
Summary
Staff failed to maintain sanitary conditions during food service, as observed when a dietary aide handled a trash can lid and then, without performing hand hygiene, proceeded to prepare and serve a hot beverage to a resident. The aide touched the handle of a cup, filled it with water, added hot chocolate mix, and stirred the drink with a straw, all after touching the trash can lid. The same hand was used to handle a scoop for powdered thickener, which was then placed back into the container without handwashing, and the prepared drink was served to a resident with the same straw. These actions were in direct violation of the facility's policy requiring hand hygiene after handling soiled equipment and before food preparation. Additionally, improper food storage practices were observed, including expired milk being used for meal preparation, open and unlabeled food items in the refrigerator and freezers, and dry goods stored in containers that were not properly sealed, labeled, or dated. The cook acknowledged using milk past its best by date, and the dietary manager confirmed the presence of unlabeled, undated, and expired food items. Facility policies required all food to be labeled, dated, and securely stored, which was not followed.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for the Payroll Based Journal (PBJ) Staffing Data Report covering the period from October 1 to December 31. The PBJ report indicated that the facility did not have licensed nursing coverage for 24 hours per day on 65 dates within the quarter, which triggered a deficiency for failing to meet the required staffing levels. However, a review of the facility's daily staffing sheets, nurse schedules, and time cards for the infraction dates showed that nursing services were provided for 24 hours per day, with coverage by the DON and several RNs. The deficiency was attributed to discrepancies in the PBJ data submission process. The facility underwent a change in management and corporation during the reporting period, resulting in a lack of access to staffing information for the earlier part of the quarter. After the management change, the process involved the Business Office Manager and Administrator submitting staffing data to the corporate PBJ software, with the corporation responsible for final submission. The facility relied on weekly detailed reports and corporate review to identify discrepancies, but the submitted PBJ data did not accurately reflect the actual staffing provided, leading to the deficiency.
Repeat Deficiencies in QAPI, Medication Management, and Food Sanitation
Penalty
Summary
The facility failed to correct previously identified deficiencies in four of fourteen areas of concern, as evidenced by repeat citations in multiple survey cycles. Specific deficiencies included failures in the QAPI program and plan, comprehensive assessments and their timing, appropriate use and documentation of psychotropic medications (including PRN use and gradual dose reduction), and food storage, preparation, and service sanitation. Surveyors observed inaccurate coding on the MDS for hospice level of care, antipsychotic and anticoagulant medication use, and urinary tract infection diagnosis. There were also failures to document non-medical interventions before administering PRN antipsychotic medications and to attempt gradual dose reductions as required. Additionally, staff were observed not following proper food safety protocols, such as failing to perform hand hygiene between touching contaminated surfaces and resident food items, and improper glove use during food service. Despite the facility's QAPI plan outlining a data-driven, proactive approach to quality improvement, these deficiencies persisted across several survey periods. The administrator acknowledged the repeat citations and described the facility's ongoing efforts to address these issues, but the report documents that the same types of deficiencies continued to be identified by surveyors.
Failure to Complete Timely MDS Entry and Discharge Assessments
Penalty
Summary
The facility failed to complete required Minimum Data Set (MDS) entry and discharge assessments within the mandated timeframes for four residents. Specifically, entry MDS assessments were not completed within 7 days for residents who were readmitted after hospital stays, and discharge MDS assessments were not completed within 14 days for residents who left the facility. Documentation showed that residents experienced hospitalizations and subsequent returns to the facility, but the necessary MDS tracking records, including entry and discharge assessments, were either incomplete or still listed as 'in progress' well after the required deadlines. Interviews and record reviews revealed that staff, including the DON, misunderstood the requirements for completing entry and discharge MDS assessments, believing they were not necessary for Medicaid residents unless the absence exceeded 10 days. The RAI Manual, however, requires these tracking records for all residents regardless of payer source or length of absence. The affected residents had complex medical histories, including conditions such as pneumonia, stroke, seizure disorder, and recent hospitalizations for acute symptoms, but the facility did not ensure timely completion and submission of the required MDS documentation.
Inaccurate MDS Coding for Medications and UTI
Penalty
Summary
The facility failed to accurately code medications and a urinary tract infection (UTI) on the Minimum Data Set (MDS) assessments for four out of fifteen residents reviewed. Specifically, one resident's Medication Administration Record (MAR) showed an order for apixaban, an anticoagulant, but their MDS assessment did not document receipt of an anticoagulant during the lookback period. Another resident's MAR listed trazodone, an antidepressant, but the MDS assessment did not reflect that the resident received an antidepressant, instead incorrectly indicating use of an antipsychotic. A third resident's MAR showed an order for clopidogrel bisulfate, an antiplatelet, but the MDS assessment incorrectly coded the resident as having received both an anticoagulant and an antiplatelet, contrary to the RAI manual instructions not to code antiplatelets as anticoagulants. Additionally, a fourth resident's MDS assessment indicated receipt of an anticoagulant, but the MAR did not show an order for such medication. This resident's MAR did include physician orders for antibiotics to treat a UTI, but the MDS assessment did not document the UTI during the lookback period. The facility's policy required that assessments be accurate and reflective of the resident's status at the time of assessment, completed by qualified staff. The DON acknowledged the MDS assessments were coded incorrectly.
Menu Not Followed and Lacked Dietician Approval
Penalty
Summary
The facility failed to follow the prescribed menu and obtain required Registered Dietician (RD) approval for menu changes and the current menu cycle. For one resident on a mechanical soft diet, the cook provided a lunch that substituted green beans for carrots and omitted baked beans, based on the Dietary Manager's (DM) decision. The DM stated that the RD approved omitting the baked beans without replacement, as the remaining items were considered nutritionally adequate. However, the RD later clarified that while she approved omitting the baked beans, she was not consulted about replacing carrots with green beans and would have required an additional carbohydrate, such as a potato, to meet nutritional needs. Additionally, the facility's current spring/summer menu lacked the RD's signature of approval. The RD reported she had not received the new menu for review and approval, and the last menu she signed was for the previous fall/winter cycle. The DM and Administrator believed the menus had been approved, but the RD confirmed she had not yet reviewed or signed the current menu. Facility policy requires menus to be prepared in advance, followed as written, and reviewed by the RD for nutritional adequacy, which was not done in this instance.
Failure to Notify Representatives of High-Risk Medication Changes
Penalty
Summary
The facility failed to notify the representatives of two residents with severe cognitive impairment about significant changes in their medication regimens. For one resident with diagnoses including anxiety, depression, and hypertension, a new order for quetiapine (an antipsychotic) was initiated, but there was no documentation that the resident's representative was informed or that consent was obtained. For another resident with Alzheimer's Disease, hypertension, and coronary artery disease, trazodone was discontinued and restarted at a different dose and frequency, yet again, there was no record of notification to the resident's representative regarding this medication change. Facility policy requires that residents or their representatives be informed of the benefits, risks, and alternatives prior to initiating or increasing medications, and that they have the right to refuse medications. Staff interviews confirmed the expectation that representatives should be notified of medication changes. However, clinical record reviews for both residents showed a lack of documentation of such notifications, constituting a failure to ensure that residents' representatives were fully informed about their health status, care, and treatments.
Failure to Assess and Authorize Resident Self-Administration of Topical Medications
Penalty
Summary
The facility failed to determine if a resident was capable of self-administering topical medications, as required by policy and clinical standards. A resident with moderately impaired cognition, as indicated by a BIMS score of 11, was observed with multiple unlabeled and labeled medication cups containing topical creams at his bedside, which he reported applying himself. The clinical record review showed that the resident had physician orders for several topical medications, including Triamcinolone, Diclofenac, and Hydrocortisone, but there was no physician order or documented assessment authorizing self-administration of these medications. The care plan noted the resident's preference to self-apply creams and lotions, but this intervention was added only after the issue was brought to the attention of the Director of Nursing. Staff interviews revealed a lack of awareness and oversight regarding the resident's self-administration of medications. One LPN stated she was responsible for applying the topical medications and was unaware the resident was self-administering them. The DON confirmed that the resident did not have an order or assessment for self-administration and acknowledged that medications should be kept in a secure place. Facility policy required a formal assessment of the resident's ability to self-administer medications and proper documentation, which was not completed in this case.
Failure to Complete Required GDR and Behavioral Documentation for Psychotropic Medications
Penalty
Summary
The facility failed to complete an annual gradual dose reduction (GDR) for an antidepressant medication for a resident with diagnoses including depression, anxiety, and bipolar disorder. The clinical record showed that the last GDR for the resident's duloxetine was completed over a year ago, and there was no documentation of a more recent attempt, despite facility policy requiring annual GDRs after the first year of use. The pharmacy had recommended against a GDR, but the required documentation and process were not completed as per policy and CMS guidelines. Additionally, the facility did not document behavioral observations or the use of nonpharmacological interventions prior to increasing the resident's antipsychotic medication, aripiprazole. The resident's records, including behavior monitoring flow sheets and the MAR, lacked evidence of observed behaviors or attempted interventions before the medication increase. The DON confirmed the absence of this documentation and acknowledged the failure to follow required procedures.
Failure to Timely Report Missing Resident Money to Authorities
Penalty
Summary
The facility failed to report incidents of missing money belonging to two residents to the Iowa Department of Inspections, Appeals, and Licensing (DIAL) and local law enforcement within the required 24-hour timeframe. In one case, a resident reported that her wallet, which contained approximately $14 and some change, went missing from her room and was later found without the money. The resident stated she informed the Administrator, but both the Administrator and the DON claimed they were only told about the missing wallet, not the missing money. In another case, a resident filed a grievance after discovering that money placed in her billfold and stored in her recliner was missing. The wallet, which previously contained bills and change, was found with only two quarters remaining. The Administrator acknowledged that, upon learning of the missing money, she contacted the corporate office and was instructed to investigate, report, and reimburse the resident. However, the Administrator admitted that the incidents were not reported to DIAL or local law enforcement as required by facility policy. Instead, the incident was reported to the Ombudsman, who visited the facility. The facility conducted an internal investigation, interviewing residents and staff, but could not determine who took the money. Facility policy mandates that any suspected crime against a resident must be reported to both DIAL and law enforcement, which was not followed in these cases.
Failure to Provide Bed Hold Notice Upon Hospital Discharge
Penalty
Summary
The facility failed to provide or offer a Bed Hold notice to a resident or the resident's representative upon discharge to the hospital, as required by facility policy and regulatory standards. Clinical record review showed that the resident, who had severe cognitive impairment and multiple complex medical diagnoses including pneumonia, viral hepatitis, wound infection, stroke, seizure disorder, traumatic brain injury, and respiratory failure, was discharged to the hospital on three separate occasions. There was no documentation in the clinical record that a Bed Hold notice was given during any of these hospitalizations. Interviews with the Administrator confirmed that the required Bed Hold documentation could not be located and that the resident's representative had not received the notice. Facility policy directed that Bed Hold information should be provided upon admission and at the time of transfer, including emergency transfers, and a copy should be filed in the resident's medical record. Despite these requirements, the necessary documentation and notification were not completed for this resident.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident following multiple falls, as required by policy and regulatory standards. Clinical record review showed that the resident, who had moderately impaired cognition and several diagnoses including hypertension, anemia, fibromyalgia, difficulty walking, unsteadiness, muscle weakness, and knee pain, experienced falls on multiple occasions. Incident reports documented falls in the resident's room, with immediate actions taken such as moving furniture and providing education to the resident. However, the care plan was not updated to reflect new interventions after falls on two specific dates, and the CNA Kardex was not revised to include these interventions for several fall events. Staff interviews confirmed that the care plan and Kardex were not updated after each fall, despite the facility's policy requiring ongoing assessment and revision of care plans as resident conditions change. The DON acknowledged the lack of updates, and both nursing and CNA staff reported relying on the Kardex for current care interventions. The deficiency was identified through clinical record review, staff interviews, and policy review, demonstrating a failure to ensure care plans were revised in response to changes in the resident's condition and fall history.
Failure to Provide Appropriate Catheter Care and Documentation
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. The resident, who was severely impaired in decision-making and had multiple diagnoses including pneumonia, viral hepatitis, wound infection, cerebrovascular accident, seizure disorder, traumatic brain injury, and respiratory failure, had physician orders for catheter care and output monitoring. However, the orders did not include a diagnosis for the catheter. The resident's care plan also lacked specific instructions for the management, assessment, handling, and maintenance of the indwelling catheter, as well as what to monitor while the catheter was in place. During observations, the resident was seen sitting in a wheelchair with the catheter bag hanging under the chair and the tubing touching the floor on multiple occasions. The DON confirmed that the care plan should address the indwelling catheter and that catheter tubing should be kept off the floor and coiled inside the privacy bag. Facility policy required documentation of the reason for catheter use and specified that catheter tubing and drainage bags should not touch the floor, but these procedures were not followed for this resident.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, as evidenced by multiple deficiencies in the administration and documentation of oxygen therapy, nebulizer treatments, and CPAP use. For one resident with severe cognitive impairment and multiple respiratory diagnoses, staff did not document oxygen administration, frequency of oxygen saturation monitoring, or maintenance of respiratory equipment. Observations revealed improper storage and dating of oxygen and nebulizer tubing, with equipment found on the floor and not consistently changed or documented as required. Another resident with moderate cognitive impairment and diagnoses including COPD and sleep apnea had a physician order for oxygen at night, but the care plan lacked any direction for oxygen or respiratory services. The resident's room contained a CPAP machine without a corresponding physician order or documentation on its administration or maintenance. The resident reported not using the CPAP due to faulty equipment, and staff were unclear about the presence and use of an oxygen concentrator. Documentation in the medical record and on the MAR/TAR was incomplete regarding both oxygen and CPAP use. A third resident with respiratory failure and COPD was observed with oxygen tubing that was not dated as required, despite an order to change tubing and clean the concentrator filter weekly. The resident confirmed that tubing was changed only after being informed of a state visit, and extra tubing was left in the room. Facility policies required physician orders, proper dating, and documentation for respiratory equipment, but these were not consistently followed, leading to lapses in safe and appropriate respiratory care.
Deficiencies in QAPI and Psychotropic Medication Documentation
Penalty
Summary
The facility failed to correct deficiencies in four out of five areas of concern, as identified in a review of their Quality Assurance Performance Improvement (QAPI) policy, past surveys, and plan of correction audit forms. During an audit of psychotropic medication use, it was found that a resident received a PRN psychotropic medication without documentation of behaviors and nonpharmacological interventions. The Director of Nursing (DON) and the Administrator (ADM) initially confirmed compliance with the audits, but later acknowledged that the audits should not have been marked as compliant due to the lack of documentation. The survey identified repeated deficiencies in the facility's QAPI program and plan, accident prevention, unnecessary psychotropic medication use, and notification of changes. The facility's QAPI plan, effective August 2024, was intended to be comprehensive and data-driven, focusing on care outcomes and quality of life. However, the ADM acknowledged ongoing concerns with repeated deficiencies and expressed frustration despite efforts to improve, noting that the facility still employed some agency nurses but no longer used agency Certified Nurse Aides.
Failure to Adhere to Safe Transfer Techniques
Penalty
Summary
The facility failed to provide safe transfer techniques for two residents, leading to deficiencies in care. Resident #1, who was diagnosed with Alzheimer's, heart failure, muscle wasting, anxiety disorder, and depression, was assessed as requiring the assistance of two staff members and a gait belt for transfers. However, staff members were observed transferring Resident #1 with only one staff member, contrary to the care plan. Interviews with staff revealed a lack of awareness regarding the required assistance level for Resident #1, indicating a failure to adhere to the care plan. Similarly, Resident #5, who had severe cognitive impairment and required substantial assistance for transfers, was transferred without a gait belt by a single staff member. This was observed by the Administrator and Director of Nursing, yet the staff member acknowledged the oversight. The facility's policy mandates the use of appropriate techniques and devices, such as gait belts, for resident transfers, and staff are expected to follow the care plan. The failure to use a gait belt and adhere to the care plan for Resident #5's transfer represents a breach of the facility's safety protocols.
Failure to Implement Dietitian's Recommendations for Resident
Penalty
Summary
The facility failed to notify the Dietitian of a new admission, Resident #5, and did not implement the Dietitian's nutritional recommendations. Resident #5, who had severe cognitive impairment and multiple health conditions including diabetes, stroke, and chronic kidney disease, was admitted to the facility without the Dietitian being informed. The Dietitian, working remotely, provided recommendations via email on 1/27/25, which included adding a diet to the electronic health record, reweighing the resident, and increasing vitamin C and zinc supplements. However, these recommendations were not acted upon by the facility. The Director of Nursing (DON) acknowledged receiving the Dietitian's recommendations but failed to ensure they were communicated to the Nurse Practitioner (NP) or implemented. The DON did not recall the recommendations for Resident #5 and had no confirmation that the NP received them. As a result, Resident #5 did not receive the necessary dietary supplements and experienced significant weight loss, which was only noted after the Dietitian returned from vacation and reviewed the resident's weight records.
Failure to Limit PRN Antipsychotic Medication and Document Non-Medicinal Interventions
Penalty
Summary
The facility failed to adhere to regulations regarding the administration of PRN antipsychotic medications, specifically haloperidol, for a resident with complex medical conditions including Alzheimer's disease and bipolar disorder. The resident's care plan included non-pharmacological interventions to manage physical aggression, yet the facility did not document attempts of these interventions before administering the PRN medication. Additionally, the facility did not limit the PRN antipsychotic drug to 14 days as required, nor did they conduct an in-person exam to justify the continuation of the medication beyond this period. The resident's medication administration records showed that haloperidol was administered on multiple occasions over a span exceeding 14 days without the necessary documentation of non-medicinal interventions or an in-person exam. The facility's administrator acknowledged the oversight and confirmed the expectation for staff to document behaviors and attempt non-medicinal interventions prior to administering PRN antipsychotic medications. This lack of documentation and failure to follow protocol led to the identified deficiency.
Failure to Document and Provide Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary interventions and document treatments for a resident with a venous ulcer on the right posterior lower leg. The resident, who had severe cognitive impairment and multiple medical conditions, including hypertension, septicemia, and malnutrition, was dependent on staff for mobility and care. Despite having a care plan in place, the facility did not complete or document the required treatments for the resident's wound, as evidenced by missing entries in the Treatment Administration Record (TAR) and clinical records from late September to mid-November. The resident's wound, which was being treated at a wound center, showed signs of deterioration over time, with measurements indicating an increase in size and the presence of necrotic tissue. The wound center provided specific instructions for wound care, including cleansing with saline and applying specific dressings, but the facility failed to document these treatments consistently. The resident's condition was further complicated by behavioral issues that led to transportation refusals, preventing the resident from attending scheduled wound center appointments. Interviews with facility staff and wound center personnel revealed that the facility was aware of the resident's treatment needs but failed to ensure consistent care. The Director of Nursing acknowledged the lack of documentation and treatment, attributing it to transportation issues and the resident's behavior. The wound center nurse confirmed that the resident's wound worsened due to comorbidities and lack of care, and the facility was expected to perform treatments per physician orders, which were not documented as completed.
Repeated Deficiencies in Professional Standards and Resident Safety
Penalty
Summary
The facility failed to correct deficiencies in four areas of concern, as identified in both the current and past surveys. These areas include ensuring services meet professional standards, maintaining an environment free of accidents and hazards with adequate supervision, implementing an effective QAPI program, and adhering to proper food procurement, storage, preparation, service, and sanitation practices. Despite having a QAPI plan in place, the facility did not successfully address these deficiencies, indicating a gap in their quality improvement processes. The Administrator acknowledged the repeated deficiencies and expressed surprise, believing the issues had been resolved. She noted challenges in staffing, particularly in hiring nurses, which led to the use of agency staff, a solution the facility was not satisfied with. The Administrator mentioned efforts to have the DON focus more on administrative duties rather than floor duties, with the goal of improving oversight and addressing physician orders. Despite these efforts, the facility continued to face significant obstacles in maintaining compliance with professional standards and ensuring resident safety.
Failure to Follow Food Service Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the preparation and distribution of food. On December 2, 2024, Staff A, a Cook/Dietary Aide, was observed plating apple pie while wearing gloves. However, Staff A touched multiple surfaces, including plates, a pie pan, and a counter, while plating the pie, which is against the facility's policy that requires gloves to be changed after touching surfaces other than ready-to-eat food. Additionally, during the noon meal, Staff A transported room trays down the hallway with two out of three servings of apple pie uncovered, contrary to the facility's policy that mandates all food be covered during transportation. On December 3, 2024, the Food Service Supervisor confirmed that all foods should be covered when transported to a resident's room and that gloves should only be used for handling ready-to-eat food, necessitating a change if other surfaces are touched. The facility's policies on Preventing Illness Employee Hygiene and Sanitary Practices and Food Preparation and Service, both revised in October 2023 and October 2024 respectively, were not followed, leading to this deficiency.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete a comprehensive assessment within 14 days of admission for one resident and did not complete a comprehensive annual assessment in a timely manner for another resident. The clinical record review and staff interviews revealed that the facility did not adhere to the required timelines for completing the Minimum Data Set (MDS) assessments. Specifically, one resident's admission MDS was not completed or started within the required timeframe, and another resident's annual MDS was also incomplete and overdue. The Director of Nursing (DON) reported that the previous management had a corporate MDS coordinator responsible for completing the MDS assessments. However, after a transition in management, the responsibility fell on the DON, who was not adequately trained for the role and was also working as a charge nurse. The administrator confirmed that the transition led to a lack of clarity regarding the responsibility for MDS completion, resulting in delays. The facility's policy required comprehensive assessments within 14 days of admission and annually, but these were not met due to the management transition and staffing issues.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly Minimum Data Set (MDS) assessment for one resident within the required timeframe. Specifically, the review of the electronic health record for a resident showed that the last quarterly MDS was completed on August 17, 2024, and there was no subsequent quarterly MDS assessment completed after that date. This oversight was identified during a record review conducted on December 4, 2024. The facility's policy, effective October 2024, assigns the responsibility of ensuring timely resident assessments to the Assessment Coordinator. However, the Director of Nursing (DON) stated that when she assumed her role, the responsibility for MDS assessments was not included, as someone from corporate was handling them. The DON, who routinely worked on the floor, attempted to complete the MDS assessments but acknowledged the need for a meeting to clarify roles and responsibilities for completing the MDS assessments. The facility had a census of 15 residents at the time of the review.
MDS Coding Inaccuracy for Hospice and Antipsychotic Medication
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident, leading to a deficiency. The resident was admitted to hospice level of care on June 27, 2024, and had their antipsychotic medication, Risperdal, discontinued on July 27, 2024. However, the MDS assessment did not document the resident's hospice level of care and incorrectly indicated that the resident took an antipsychotic medication during the lookback period. This discrepancy was acknowledged by the Director of Nursing (DON) during an interview, who confirmed that the MDS was not coded correctly regarding hospice care and the antipsychotic medication.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to implement a discharge planning process for a resident who was discharged to another nursing facility. The resident, who had a BIMS score of 14 indicating no cognitive impairment, had multiple diagnoses including non-traumatic brain dysfunction, hemiplegia, stroke, non-Alzheimer's dementia, Parkinson's, and a seizure disorder. Despite the resident's mental capacity to make decisions, the facility did not include discharge planning in the Baseline Care Plan or the Care Plan in effect at the time of discharge. The clinical record also lacked documentation of the resident's wish to transfer and did not show that the resident's contact participated in the discharge planning. The facility's progress notes indicated that the resident's primary care provider was aware of the discharge, but the facility awaited signed orders. The resident was discharged to another nursing facility without a documented transfer form, and the discharge was facilitated by a staff member using their personal vehicle. An email from the DON confirmed that the resident had requested to move closer to their spouse, but the facility failed to return phone calls from the desired facility. The facility's policy required a discharge summary and post-discharge plan to assist the resident in adjusting to a new living environment, which was not developed in this case.
Failure to Provide Recapitulation of Resident's Stay at Discharge
Penalty
Summary
The facility failed to ensure a recapitulation of a resident's stay at the time of discharge, which is a requirement according to their policy. Resident #6, who had a high Brief Interview for Mental Status (BIMS) score indicating no cognitive impairment, was discharged to another nursing facility. The resident had a medical history that included non-traumatic brain dysfunction, hemiplegia, stroke, non-Alzheimer's dementia, Parkinson's, and a seizure disorder. The discharge was documented in a progress note, which stated that the resident took all their belongings and was transported in a staff member's personal vehicle, with all signed paperwork sent with the resident. However, the clinical record did not include a recapitulation of the resident's stay, which is a necessary component of the discharge summary as per the facility's policy revised in November 2017.
Inadequate Supervision Leads to Falls and Altercations
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent accidents and incidents for two residents. One resident, who had severe cognitive impairment and was dependent on staff for mobility and toileting, experienced multiple falls. The facility's incident reports documented several falls where the resident attempted to pick up items from the floor without assistance, resulting in falls from their wheelchair. The facility did not consistently notify the resident's family or physician of these falls, nor did they implement effective interventions to prevent future incidents. Another resident, who had severe cognitive impairments and a history of aggressive behavior, was involved in multiple altercations with other residents. The resident exhibited physical and verbal aggression, including pulling another resident's headphones and jabbing a spoon towards a resident's face. Despite these behaviors, the facility did not provide adequate supervision to prevent these altercations, and staff interventions were reactive rather than preventive. The facility's policies required notification of the physician and family after falls, as well as the implementation of new interventions and documentation in the resident's medical record. However, these steps were not consistently followed, and the facility failed to identify trends or conduct root cause analyses to address the underlying issues. The lack of effective supervision and failure to implement preventive measures contributed to the ongoing incidents and altercations.
Failure to Provide Clinical Rationale for Medication Regimen
Penalty
Summary
The facility failed to provide an appropriate clinical rationale for declining a gradual dose reduction (GDR) for a resident's medication regimen. The resident, who was diagnosed with anxiety, depression, diabetes mellitus, and renal insufficiency, was receiving both an antidepressant and an antipsychotic medication. The facility's Minimum Data Set (MDS) assessment for the resident was incomplete, lacking a Brief Interview for Mental Status (BIMS) score and staff assessment for cognitive patterns. The Clinical Physicians Orders included prescriptions for quetiapine fumarate and sertraline, but the Consultation Report regarding the GDR request for quetiapine was incomplete. The Psychiatric Subsequent assessment lacked documentation of the clinical rationale for the continued use of these medications. The Director of Nursing (DON) indicated that the physician addressed GDRs in progress notes or the Psychiatric Subsequent Assessment, but the review of the assessment did not provide sufficient documentation. The facility's Medication Regimen Reviews policy required the consultant pharmacist to review medication regimens following state and federal guidelines, including the need for GDRs and behavioral interventions unless contraindicated. However, the facility did not adhere to these guidelines, resulting in the deficiency.
Failure to Document Non-Medical Interventions Before Administering Antipsychotic Medication
Penalty
Summary
The facility failed to document non-medical interventions prior to administering an as-needed antipsychotic medication to a resident. The resident, who had a history of non-Alzheimer's dementia, seizure disorder, anxiety disorder, bipolar disorder, and intermittent explosive disorder, exhibited aggressive behaviors towards other residents. Despite these behaviors, the facility's records lacked documentation of any non-pharmacological interventions attempted before administering haloperidol, an antipsychotic medication. Additionally, there was no documentation of adverse drug reactions, side effects, or the effectiveness of the medication. Observations and staff interviews revealed multiple incidents involving the resident's aggressive behavior, such as pulling another resident's headphones, turning lights on and off, and jabbing a spoon towards another resident's face. The facility's Director of Nursing (DON) reported that non-medical interventions included offering food or taking the resident back to his room, but these were not documented in the progress notes. The Treatment Administration Record (TAR) and Point of Care Response History also lacked documentation of the resident's behaviors or any behavioral interventions attempted on the day the medication was administered.
Documentation Failures in Medication Administration and Fall Reporting
Penalty
Summary
The facility failed to maintain accurate documentation of medical records for two residents, leading to deficiencies in care. For one resident, the facility did not document the administration of an as-needed antipsychotic medication, haloperidol, which was given to manage aggressive behaviors. The Medication Administration Record (MAR) lacked the physician's order for the medication, and there was no documentation of non-medicinal interventions, adverse drug reactions, side effects, or the effectiveness of the medication. The Director of Nursing (DON) acknowledged the oversight in not entering the order into the MAR, which resulted in a lack of follow-up on the resident's condition after receiving the medication. For another resident, the facility failed to document a fall in the progress notes or notify the resident's physician and family. The resident, who had severe cognitive impairment and was dependent on staff for mobility, was found on the floor after attempting to pick something up. The incident report and clinical record did not include necessary details such as the condition of the resident when found, assessment data, or notification of the physician and family. The DON confirmed that the agency nurse did not complete all required documentation steps following the fall.
Inadequate Infection Control Practices for Resident with Open Wounds
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections for a resident with severe cognitive impairment and multiple medical conditions, including a venous ulcer and cellulitis. The resident was dependent on staff for mobility and toileting, and the care plan included enhanced barrier precautions (EBP) due to open wounds. However, during the survey, it was observed that there was no EBP signage on the resident's door, and personal protective equipment (PPE) supplies were not maintained outside the room as required by the care plan. During a wound care procedure, the Director of Nursing (DON) did not follow proper infection control protocols. The DON did not perform hand hygiene before putting on gloves, used the same pair of gloves throughout the procedure without changing them, and did not perform hand hygiene after removing the gloves. Additionally, the DON did not wear a gown during the procedure, which was acknowledged as a requirement for high-contact resident care activities. The DON also used a gown intended for personal protection as a barrier for supplies instead. The facility's policies on multidrug-resistant organisms (MDRO), enhanced barrier precautions, and hand hygiene were not adhered to during the care of the resident. The policies required the use of gloves and gowns during high-contact activities and emphasized hand hygiene as the primary means to prevent infection spread. The facility's failure to implement these precautions and protocols contributed to the deficiency in providing a safe and sanitary environment for the resident.
Failure to Notify Physicians and Families of Incidents
Penalty
Summary
The facility failed to notify and document the physician and family for three residents regarding significant incidents affecting their care. Resident #3, who had severe cognitive impairment and multiple medical conditions, experienced two falls. The first fall occurred when the resident was found on the floor after attempting to retrieve something from his wheelchair. Although the incident report noted that the administrator, DON, and physician were notified, there was no documentation of family notification. In a second incident, the resident fell again while trying to pick something up, but neither the physician nor the family was notified. The facility's policy required notification of both the physician and family after a fall, which was not adhered to in these cases. Resident #11, with moderately impaired cognition and several medical diagnoses, reported verbal abuse by a CNA. The facility documented the incident and took action by suspending the CNA and conducting follow-ups with the resident. However, the clinical record lacked documentation of notification to the resident's primary physician about the abuse allegations. The DON acknowledged the oversight, having only contacted the mental health provider, who later had no recollection of the incident. The facility's policy mandated prompt notification of the physician and resident representative for changes in the resident's condition or status, which was not followed. Resident #9, also with severe cognitive impairment and multiple health issues, was involved in a facility-reported incident. The electronic health record did not show family notification for this incident. The DON admitted that the family was not informed until the outcome of the incident was clear. A text message exchange between the administrator and a family member revealed uncertainty about whether a medication error related to the incident was discussed. The facility's failure to notify the family promptly was contrary to their policy requirements.
Failure to Obtain Physician's Order for Ready Wraps
Penalty
Summary
The facility failed to obtain a physician's order for the application of Ready Wraps, specialized wraps used to manage edema, for a resident. The resident, who had intact cognition and required substantial assistance with dressing, was instructed by an Occupational Therapist at a Lymphedema Clinic to use the Ready Wraps. However, the facility did not contact the physician to secure an order for their use. The Treatment Administration Records for October, November, and December 2024 did not include an order for the application and removal of the Ready Wraps. Observations and interviews revealed that the resident did not have the wraps applied on multiple occasions, despite needing assistance from staff to do so. The Director of Nursing (DON) acknowledged that the wraps were not listed on the Treatment Administration Records or the Care Plan and stated that they would be added. The facility's policy required that all medication and treatment protocols be ordered by the resident's attending physician or designee, and that all physician's orders be appropriately transcribed and noted by a licensed nurse. The facility administrator confirmed that no order had been placed for the Ready Wraps, despite instructions from the Lymphedema Clinic.
Improper Medication Destruction and Documentation
Penalty
Summary
The facility failed to properly handle the destruction of medications for one resident, leading to a deficiency in pharmaceutical services. During a facility investigation, it was revealed that the facility did not maintain a record of medications returned to the pharmacy, except for 35 tablets of Depakote. A registered nurse admitted to tearing the top off the bubble pack, punching out the remaining medications, and discarding the bubble pack without proper documentation. The nurse stated she destroyed the leftover medication in the drug buster but did not document the destruction as required by the facility's policy. The facility's policy on discarding and destroying medications requires that medications not returned to the pharmacy be destroyed according to state regulations, with a medication disposition record signed by witnesses. This record must include details such as the resident's name, date of destruction, medication details, and method of destruction. However, the nurse involved was unaware of the requirement to return medications to the pharmacy and failed to document the destruction process, leading to a breach in the facility's medication management protocol.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of unsanitary conditions and improper food storage practices. During an inspection, a build-up of dust, dirt, and debris was noted along the side of the oven, on the floor beside and behind the oven, and along the floor and baseboard near the kitchen's main door. Additionally, dried food and debris were found inside the kitchen refrigerator, and several food items, including a cheese sandwich, mayonnaise, non-fat vanilla yogurt, beef soup base, and shredded mild cheddar cheese, were not labeled or dated as to when they were opened. Further observations revealed unsanitary conditions in the basement area, where a brown, sticky substance, dirt, and debris were found, along with opened frozen hot dog buns that were not dated. The chest freezer in the basement contained a build-up of dirt, debris, frost, and ice, and an opened, unlabeled, and undated box with a plastic bag containing pizza crusts. Additionally, a plastic bag with frozen pre-made omelettes and a box of opened ice cream sandwiches were not labeled or dated. Gallon jugs of white and chocolate milk, as well as two pitchers of juice, were also found without labels or dates in a serving bin with ice near the kitchen's North door.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit accurate staffing data for the CMS Payroll Based Journal (PBJ) Staffing Data Report for the period from January 1 to March 31. The report identified multiple dates where there was a failure to have licensed nurse coverage 24 hours a day. The facility's daily assignment sheets indicated that the Director of Nursing (DON), MDS Coordinator, and agency staff covered the nursing shifts on these dates. However, the salaried and agency staff did not clock in and out, leading to inaccuracies in the reported staffing data. The Administrator acknowledged that the data submitted for the PBJ did not accurately reflect the nursing hours worked by the nursing administration and agency staff. The facility had a procedure in place for salaried nurses to fill out a missed punch form, which was then sent to the HR manager or Administrator and subsequently to the Payroll Department for recording on the PBJ dashboard. Despite this procedure, the failure to ensure accurate data submission resulted in the deficiency noted in the report.
Facility Fails to Correct Deficiencies in QAPI and Care Standards
Penalty
Summary
The facility failed to correct deficiencies in three of six areas of concern, as identified in their Quality Assurance Performance Improvement (QAPI) plan and past surveys. The deficiencies included services not meeting professional standards, lack of accident/hazard prevention and supervision, and issues with the QAPI program/plan itself. The facility's mission is to maximize the quality of resident care and services through a systematic and interdisciplinary approach, but they have not achieved this due to ongoing issues. The Regional Nurse Consultant noted challenges with agency staffing, as temporary staff only perform their immediate tasks, and the Director of Nursing (DON) is often required to work on the floor, preventing her from fulfilling her administrative duties.
Failure to Provide Supervision During Ambulation
Penalty
Summary
The facility failed to provide professional standards of care by not adhering to physician orders for a resident requiring supervision during ambulation. The resident, who had diagnoses of non-Alzheimer's disease, anxiety disorder, and depression, was assessed as rarely or never understood, and had a history of numerous falls over the past six months. Despite a physician's order dated February 7, 2024, for the resident to have supervision when walking long distances in the hallway, the facility did not implement this order. The resident's care plan also lacked information regarding the need for supervision with ambulation, resulting in the resident continuing to ambulate and transfer independently without the required supervision.
Failure to Conduct Root Cause Analysis and Implement Effective Fall Interventions
Penalty
Summary
The facility failed to conduct a root cause analysis or determine a conclusion for each fall experienced by a resident, who had a history of repeated falls, totaling 15 incidents in the previous six months. The resident, identified as having a risk for falls due to dementia and the use of psychotropic medication, had severely impaired decision-making skills and memory problems. Despite the implementation of various interventions, such as gripper strips, encouraging the use of glasses, and toileting schedules, the resident continued to experience falls, indicating a lack of effective intervention and supervision. The facility's policy on fall prevention aimed to reduce fall risks through a comprehensive assessment and intervention strategy. However, the facility did not adequately implement these strategies for the resident in question. The Director of Nursing and Regional Nurse Consultant mentioned using the 'five whys' method for root cause analysis, but the continued falls suggest that this process was either not effectively carried out or the interventions were not appropriately tailored to the resident's needs. The facility's failure to provide adequate supervision and effective interventions as directed by the Care Plan contributed to the ongoing fall incidents.
Inadequate Bowel Management Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate bowel management assessments, interventions, and physician notifications for a resident, leading to a fecal impaction and subsequent hospitalization. The resident, who had a history of constipation and was always incontinent of bowel and bladder, refused bowel management interventions such as suppositories and enemas. Despite this, the care plan lacked specific directions on how to manage the resident's bowel patterns, including when to notify the physician about constipation issues. The progress notes revealed significant gaps in documentation and communication. Over several months, the resident went multiple days without a bowel movement, sometimes up to 19 days, without proper bowel assessments or physician notifications. The staff documented refusals of interventions but failed to follow up with alternative strategies or notify the physician about the resident's ongoing constipation and refusal of care. This lack of action and documentation persisted even when the resident showed signs of discomfort and abdominal pain. The situation escalated when the resident experienced severe abdominal pain, nausea, and shortness of breath, leading to an emergency hospital visit. Hospital records confirmed a fecal impaction and significant abdominal distention. The facility's policy on incontinence management was not effectively implemented, as there were no standing orders for constipation, and the staff did not consistently assess or document the resident's bowel condition. The facility's failure to manage the resident's bowel care appropriately resulted in a serious health event requiring hospitalization.
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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