Aspire Of Pleasant Valley
Inspection history, citations, penalties and survey trends for this long-term care facility in Pleasant Valley, Iowa.
- Location
- 17990 Spencer Road, Pleasant Valley, Iowa 52767
- CMS Provider Number
- 165376
- Inspections on file
- 34
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Aspire Of Pleasant Valley during CMS and state inspections, most recent first.
A resident with multiple venous ulcers and an ESBL-positive infection did not receive wound care in accordance with infection control protocols. Nursing staff failed to perform hand hygiene, change gloves between tasks, disinfect reusable equipment, and consistently conduct wound care in the resident's room, as required by facility policy. Staff interviews confirmed lapses in following proper procedures during wound dressing changes.
The facility did not maintain an effective pest control program, resulting in reports and evidence of ants and mice in resident rooms. A resident with intact cognition reported seeing ants and an incident involving a mouse in her bed, while another resident confirmed the presence of a mouse and a mouse trap in his room. Staff interviews indicated past issues with mice, especially in rooms where food was kept, and the facility's pest control contract had lapsed without the administrator's knowledge.
A resident with severely impaired cognition and at moderate risk for pressure ulcers developed a Stage 3 pressure ulcer due to the facility's failure to notify the physician of wound deterioration and implement nutritional orders. The resident's condition worsened, leading to hospital admission for a complicated wound infection. The facility did not follow up on physician orders or provide consistent wound assessments, contributing to the resident's declining health.
A resident with diabetes and other health conditions did not consistently receive meals that met her vegetarian preferences, leading to skipped meals. Despite her ability to express dietary preferences, the facility failed to provide appropriate meal substitutions, and the alternate menu lacked Registered Dietician authorization.
The facility's QAPI program was found ineffective, with repeated deficiencies in nursing staff sufficiency, ADL care, quality of care, food service, and infection control. Despite quarterly QAPI meetings, the lack of an improvement plan for previous deficiencies contributed to their recurrence.
The facility failed to maintain adequate staffing levels, leading to multiple shifts with insufficient CNAs. This shortage contributed to an incident where a CNA, overwhelmed by stress, threw a box of gloves at a resident during a verbal altercation. The resident, who required assistance for daily activities, was indirectly hit by the gloves. The facility's administrator acknowledged the staffing issues and attempted to manage staff burnout, but high turnover and call-ins continued to affect care quality.
The facility failed to ensure the Dietary Manager had the required national certification for food service management and safety. Despite being hired over a year ago, the Dietary Manager faced interruptions in taking the certification test, including a test shutdown and work obligations. The facility also lacked a policy on necessary certifications for Dietary Managers, and the dietician worked remotely without an on-site schedule.
The facility failed to properly prepare pureed meals for residents, as the Dietary Manager did not measure food portions before or after blending, leading to incorrect serving sizes. The facility's policy lacked guidance on measuring pureed foods, contributing to the deficiency.
The facility failed to maintain proper food safety and hygiene practices, leading to potential cross-contamination. Staff did not perform adequate hand hygiene, and several food items were improperly stored. Uncovered garbage cans and inadequate chemical concentration in cleaning solutions were also noted. The facility's policy lacked specific instructions on these issues.
The facility failed to serve food at safe and palatable temperatures, as evidenced by resident complaints and test tray observations. A resident reported overcooked vegetables and cold food, while a test tray showed food temperatures below the expected 145 F. The Dietary Manager acknowledged the need for additional steps to maintain food warmth, and the facility's HACCP Procedures Manual set a minimum holding temperature of 135 F.
A facility failed to implement Enhanced Barrier Precautions during wound care for two residents and while emptying a urinary catheter collection bag for another. Despite the presence of signs and PPE, staff did not wear gowns as required by the facility's infection control policy. Interviews confirmed the expectation to use gowns and gloves, which was not adhered to, leading to deficiencies in infection control practices.
A resident with quadriplegia did not receive necessary range of motion (ROM) exercises due to the facility's failure to include these in the care plan and the absence of a restorative nursing program. The resident, dependent on staff for daily activities, expressed frustration over the lack of therapy. Interviews with staff confirmed the deficiency, with the DON acknowledging the need for ROM exercises and the PTA noting the absence of recommendations due to the lack of a restorative program.
A resident with multiple sclerosis and muscle weakness developed 2+ pitting edema in both lower legs and feet, but the facility failed to notify the physician or document any follow-up interventions. The care plan required monitoring and physician notification for edema, but this was not done, and the physician's notes did not address the condition. The DON confirmed the lack of documentation and follow-up.
The facility failed to provide pneumococcal and influenza immunizations as required for two residents. One resident's record showed no pneumococcal vaccine offered or declined since the last administration, and another had no record of influenza vaccine offered or declined. The MDS Coordinator confirmed missing permission forms and was unsure if vaccines were refused or not offered. Facility policy mandates annual influenza and pneumococcal immunizations unless contraindicated or refused, with documentation required.
A resident experienced physical abuse when a CNA, overwhelmed by understaffing and personal stress, threw a box of gloves at the resident. The incident occurred in a facility where the resident, who had intact cognition and required assistance with daily activities, was verbally aggressive. The CNA, who was described as generally providing good care, was stressed due to understaffing and personal issues, leading to the incident.
A facility failed to separate a CNA from residents after an alleged abuse incident involving a resident with intact cognition. The CNA, frustrated during an understaffed shift, threw soapy washcloths and a box of gloves at the resident, reportedly hitting them. Despite the facility's policy requiring immediate suspension of accused staff, the CNA continued to care for another resident before being asked to leave. The administrator acknowledged the failure to follow policy, emphasizing the facility's zero tolerance for abuse.
A facility failed to prime an insulin pen before administration and did not follow physician orders for a resident readmitted after hospitalization. An LPN administered insulin without priming the pen, unaware of the requirement, and the facility's policy lacked instructions on priming. Additionally, physician orders for insulin, glucose monitoring, and Vitamin D were not transcribed correctly for a cognitively intact resident, leading to a delay in implementation. The facility had several new admissions and only one floor nurse to double-check orders, contributing to the oversight.
Two residents with significant mobility impairments did not receive the required number of baths due to staffing shortages. Despite facility policies mandating regular bathing, both residents reported missed baths, and staff interviews confirmed that insufficient staffing often led to incomplete care. Documentation inconsistencies were also noted.
The facility failed to act on a high white blood cell count for a resident, delaying necessary medical intervention for two days, and did not document or notify a physician about another resident's edema. These oversights led to deficiencies in care, as revealed by staff interviews and record reviews.
A facility failed to perform dressing changes as ordered for a resident with a stage 4 pressure ulcer, particularly over weekends, leading to the wound enlarging. The resident, who was cognitively intact and dependent on staff, reported that dressings were not changed on weekends. An LPN confirmed finding unchanged dressings after weekends and reported this to the DON. The facility's skin management policy did not address the completion of dressing changes as ordered.
A resident, dependent on staff for transfers due to conditions like chronic pain and COPD, was improperly transferred without a mechanical lift, contrary to their Care Plan. This led to a fall involving the resident and two CNAs. Staff interviews confirmed the lift was not used as required, and the facility's Administrator was unaware of the incident.
A resident undergoing dialysis reported missing meals due to insufficient staff assistance after returning from treatment. The resident, who required help with eating, often did not receive food after dialysis and was sometimes given a peanut butter and jelly sandwich after using the call light. Staff interviews confirmed the resident was occasionally forgotten for meals, and a former cook frequently overlooked the resident's needs.
Failure to Follow Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to implement proper infection control practices during wound dressing changes for a resident with multiple venous ulcers and a history of sepsis, renal insufficiency, and an ESBL-positive urinary tract infection. The resident required substantial assistance with activities of daily living and was on contact precautions due to infection risk. Facility policy required staff to don isolation gowns and gloves, perform hand hygiene, disinfect reusable equipment, and conduct wound care in the resident's room. Observations and interviews revealed that nursing staff did not consistently follow these protocols. One nurse was observed changing the resident's dressing at the nurse's station, failing to clean the wound, neglecting hand hygiene, and placing used items, including scissors, back into the medication cart without disinfection. Another nurse, during wound care in the resident's room, failed to change gloves or perform hand hygiene between tasks, used the same gauze to cleanse multiple wounds, and did not disinfect scissors between uses. The nurse also left the room wearing the isolation gown and handled supplies and equipment without appropriate glove changes or hand hygiene. Staff interviews confirmed a lack of adherence to infection control procedures, with admissions of forgetting to disinfect scissors and not always changing gloves or performing hand hygiene as required. The Director of Nursing stated that the expectation was for wound care to be completed in the resident's room with proper use of personal protective equipment, hand hygiene, and disinfection of reusable supplies, in accordance with facility policy. However, these practices were not consistently followed, as evidenced by direct observation and staff statements.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of ants and evidence of vermin within resident rooms. One resident with intact cognition reported seeing ants in her room over the past month and described an incident involving a mouse and baby mice in her bed, which she reported to staff. Observations in her room revealed no visible ants but did find debris resembling mouse droppings and food items stored on night stands, including fruit and bottled water. Another resident, also with intact cognition, confirmed the presence of a mouse in his room and pointed out a mouse trap placed along the wall. Multiple CNAs interviewed acknowledged hearing about or previously seeing mice in the facility, particularly in rooms where residents kept food, but none reported recent sightings of ants or mice themselves. The facility's pest control contract had lapsed after the last service in December, and the administrator was unaware that services had stopped until contacting the provider during the survey. The facility's policy required an ongoing pest control program to keep the building free of insects and rodents, but this was not maintained, as evidenced by resident and staff reports, physical observations, and the lack of current pest control services.
Failure to Manage Pressure Ulcer and Nutritional Needs
Penalty
Summary
The facility failed to notify the physician of pressure ulcer deterioration and implement nutritional orders to promote healing for a resident with a Stage 3 pressure ulcer. The resident, who had severely impaired cognition and was at moderate risk for pressure ulcers, was admitted with a surgical wound and skin tears but no pressure ulcers. Despite being identified as at risk, the facility did not implement a care plan for wound management or address the resident's protein calorie malnutrition. The resident developed a Stage 3 pressure ulcer on the right gluteus, which was not properly managed. The facility did not notify the physician of the wound's deterioration or the heavy saturation of the dressing. Nutritional recommendations from the dietician, including high-protein supplementation, were not implemented. The facility also failed to transcribe and implement orders from the wound clinic, including increased protein intake and specific wound care instructions. The resident's condition worsened, leading to hospital admission for a complicated wound infection and urinary tract infection. The facility's documentation was inconsistent, with missing wound assessments and failure to follow up on physician orders. The lack of proper wound care and nutritional support contributed to the deterioration of the resident's pressure ulcer, resulting in further complications and hospital readmission.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that met the individual preferences of a resident, who was one of seven residents reviewed. The resident, who had intact cognition, was diagnosed with diabetes, congestive heart failure, peripheral vascular disease, and anxiety. The resident required substantial assistance for various activities but was able to feed herself and express her preferences. Despite her preference for a vegetarian diet, the facility did not consistently accommodate her dietary choices, leading to instances where she did not receive meals aligned with her preferences. On one occasion, the resident received a hot dog for lunch, which she did not care for, and requested a peanut butter and jelly sandwich instead. Although she eventually received the sandwich, there were times when her requests for meal substitutions were not fulfilled, resulting in her skipping meals. The resident reported an incident where she received a supper tray with beef, requested a substitution, but was not provided with an alternative, leading her to skip the meal entirely. The facility's interim off-site Registered Dietician was unaware of the resident's vegetarian preference and expressed concern about the resident missing meals, especially given her insulin-dependent diabetes and other health conditions. The facility's policy required that all residents' diets be served according to the physician's order, but the alternate menu provided did not have the authorization of a Registered Dietician, indicating a lapse in adherence to dietary protocols.
Repeated Deficiencies in QAPI Program
Penalty
Summary
The facility failed to ensure a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified during multiple surveys. The deficiencies included insufficient nursing staff (F725), inadequate activities of daily living (ADL) care for dependent residents (F677), poor quality of care (F684), issues with the nutritive value, appearance, and temperature of food (F804), unsanitary food procurement, storage, preparation, and serving (F812), and lapses in infection prevention and control (F880). These deficiencies were noted during recertification and complaint surveys conducted over several periods, indicating a persistent issue with the facility's quality management processes. During an interview, the Administrator acknowledged that the QAPI team meets at least quarterly, aiming for monthly meetings to address issues. However, there was no plan in place for improving previous survey deficiencies when the current Administrator assumed her position, which contributed to the recurrence of these issues. The facility's QAPI Management Plan, revised in January 2024, outlines the responsibilities of the QAPI Committee, including monitoring and evaluating improvement plans, but it appears these measures were not effectively implemented, leading to the repeated deficiencies.
Staffing Shortages and Resident Incident
Penalty
Summary
The facility failed to employ sufficient numbers of staff to meet the needs of its residents, as evidenced by a review of the Facility Assessment and staff schedules. The assessment indicated that three Certified Nursing Assistants (CNAs) were required for both the first and second shifts when the census was 30 or more. However, the staff schedules from August 1 to September 2, 2024, showed that there were only two CNAs for either partial or whole shifts on multiple occasions. Interviews with staff members confirmed that they often felt understaffed, which affected their ability to complete their duties effectively. The facility's administrator acknowledged the staffing issues, citing staff turnover and call-ins as contributing factors. In a specific incident involving Resident #16, who had diagnoses including depression and chronic obstructive pulmonary disease, the facility's understaffing contributed to a situation where a CNA, Staff F, became overwhelmed and acted inappropriately. The resident, who was dependent on staff for various activities of daily living, was involved in a verbal altercation with Staff F, who then threw a box of gloves that indirectly hit the resident. This incident occurred on a day when the facility was short-staffed, with only three staff members present, including Staff F, Staff H (an RN), and Staff N (a CNA who was unable to assist with lifting due to pregnancy). The facility's administrator was aware of the potential for staff burnout and attempted to manage it by monitoring staff energy levels and attitudes. However, the ongoing staffing shortages and high turnover rates contributed to a stressful work environment, which may have exacerbated the situation leading to the incident with Resident #16. The administrator noted that they tried to limit overtime and fill shifts with available staff, but the challenges persisted, impacting the quality of care provided to residents.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the minimum qualifications of having a national certification for food service management and safety within the required timeframe. The Dietary Manager was hired on 6/21/22, but as of the report date, the facility lacked records of her education or certification. The Administrator acknowledged that the Dietary Manager had attempted to take the certification test but faced interruptions, including a test shutdown and being called into work due to a cook cancellation. The test was rescheduled for the following week. Additionally, the facility did not have a policy indicating the necessary certification for Dietary Managers. The dietician, who works remotely, was never on-site, and the facility was unable to produce a schedule for her.
Deficiency in Pureed Food Preparation
Penalty
Summary
The facility failed to ensure that food was properly prepared and appropriate to meet the needs of residents on a pureed diet. During an observation, the Dietary Manager (DM) did not measure the beef before blending it for four residents, and the resulting puree was not measured before being served. Similarly, carrots were blended without measuring the volume afterward, and an incorrect scoop size was used to serve them. Additionally, chocolate chip cookies were blended with an unknown quantity of milk and served without measuring, and bread and gravy were not prepared or served as part of the meal. The DM explained that she had been trained by different managers who taught her two different methods for pureeing food, one of which involved using a total volume chart to determine serving sizes, which she does not use. The facility's undated policy on pureed food preparation directed staff to portion out items before blending and to use only nutritive liquids for consistency, but it did not provide guidance on measuring foods after blending to ensure adequate serving sizes. This lack of adherence to proper procedures and the absence of clear policy guidelines contributed to the deficiency in food preparation for residents requiring pureed diets.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene practices, leading to potential cross-contamination during meal preparation and service. Observations revealed that staff did not perform adequate hand hygiene, as evidenced by a staff member wearing gloves while handling various kitchen items and then plating food without changing gloves. Another staff member washed dirty dishes and then prepared a drink mix without washing hands. Additionally, the facility's kitchen had uncovered garbage cans, which were previously identified as an issue, and the cleaning solution used for sanitizing surfaces lacked the appropriate chemical concentration. Further inspection of the kitchen storage areas showed several food items in the freezer that were opened, unsealed, and undated, including cookie dough, chicken nuggets, ravioli, pizza crust, sausage patties, and sausage links. In the dry goods pantry, almond extract was found with a broken lid, unsealed, and undated. The facility's policy, titled HACCP Procedures Manual, directed staff to use proper hand washing and handling techniques to prevent infections but lacked specific instructions regarding garbage can coverage, chemical sanitization, and proper labeling and dating of opened food items.
Deficiency in Serving Food at Safe and Palatable Temperatures
Penalty
Summary
The facility failed to serve food at a safe temperature and ensure it was palatable, as evidenced by multiple findings. A review of the Resident Council Minutes from May 2024 revealed complaints about food sometimes being cold. During an interview, a resident described the vegetables as overcooked and the hamburger as tasting like sandpaper, noting that the food was not warm when delivered to his room. An observation of a test tray showed that the mashed potatoes were at 135.5 degrees Fahrenheit, boiled carrots at 125.0 F, and roast beef at 120.5 F, with the carrots and roast beef noted to be lukewarm and the carrots having a mushy consistency. The Dietary Manager stated that she expected food holding temperatures to be around 145 F and acknowledged that additional steps might be needed to keep room trays warm. The facility's undated HACCP Procedures Manual indicated that the minimum acceptable holding temperature for all hot foods should be 135 F and directed staff to prevent soggy, overcooked vegetables.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control protocols by not implementing Enhanced Barrier Precautions (EBP) during wound care for two residents and while emptying a urinary catheter collection bag for another resident. Resident #15, who was cognitively intact and dependent on staff for various activities, had a care plan that required EBP due to wounds. However, during wound care, staff did not wear gowns as required, despite the presence of an EBP sign and adequate PPE supplies outside the room. Staff D, LPN, and Staff E, CNA, both failed to don gowns while performing wound care, which was against the facility's infection control policy. Resident #87, also cognitively intact and dependent on staff, had wounds on the back and required wound care. Although the care plan did not specifically address EBP, the presence of an EBP sign and PPE supplies indicated the need for such precautions. Staff D, LPN, did not wear a gown while performing wound care, and admitted during an interview that a gown should have been worn. The facility's policy required the use of a gown and gloves for wound care, which was not followed in this instance. Resident #86, who had an indwelling catheter and required EBP, did not receive care in accordance with these precautions. Staff B, CNA, emptied the urinary catheter collection bag without donning a gown, despite the EBP sign and available PPE. Interviews with staff confirmed the expectation to wear gowns and gloves for such procedures, which was not adhered to. The facility's policy clearly outlined the need for gown and glove use during high-contact care activities, including those involving catheters, which was not followed in this case.
Failure to Provide Range of Motion Exercises for Quadriplegic Resident
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) exercises for a resident with quadriplegia, leading to a deficiency in maintaining the resident's current level of ROM. The resident, who has intact cognition, is dependent on staff for activities of daily living due to limited mobility and requires assistance for transfers, bathing, dressing, and personal hygiene. The care plan for the resident did not include directives for staff to perform ROM exercises, and both the occupational and physical therapy discharge summaries lacked recommendations for a restorative or functional maintenance program. Interviews with the resident and staff revealed that the resident was not receiving any therapy or ROM exercises, which was a source of frustration for the resident. The Director of Nursing acknowledged the absence of a restorative nursing program and the need for staff to provide ROM exercises for residents unable to perform them independently. A physical therapy assistant confirmed that no recommendations for restorative nursing were made due to the lack of such a program at the facility, despite the necessity of passive ROM exercises to prevent contractures.
Failure to Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to ensure that a physician provided orders for a resident's immediate care and needs following a change in condition. Resident #33, who had diagnoses including multiple sclerosis, muscle weakness, and difficulty walking, was noted to have 2+ pitting edema in both lower legs and feet during skilled evaluations. Despite the facility's policy requiring physician notification and intervention for such conditions, there was no documentation indicating that the physician was informed of the edema or that any follow-up interventions were implemented. The resident's care plan included monitoring for edema and notifying the physician, yet this was not adhered to. The physician's progress notes did not address the resident's recent edema, and the resident reported only meeting the physician once without examination. Interviews with the Director of Nursing confirmed the lack of documentation and follow-up regarding the resident's edema, highlighting a failure in communication and adherence to the facility's policy for managing changes in a resident's condition.
Failure to Provide Required Immunizations
Penalty
Summary
The facility failed to provide pneumococcal and influenza immunizations as required for two out of five residents reviewed. Resident #10's immunization record indicated the last pneumococcal vaccine was administered on 8/27/22, with no record of the vaccine being offered or declined since then. Similarly, Resident #19's record showed the last influenza vaccine was administered on 10/07/22, with no subsequent record of the vaccine being offered or declined. During an interview, the MDS Coordinator admitted to not having a permission form for Resident #10 and was unsure if the resident refused or was not offered the vaccine. Additionally, there was no declination or acceptance form for Resident #19's influenza vaccine. The facility's policy requires all residents to receive annual influenza vaccines and pneumococcal immunizations unless contraindicated or refused, with documentation to be placed in the medical record.
Resident Abuse Due to Staff Overwhelm and Understaffing
Penalty
Summary
The facility failed to protect a resident from physical abuse when a staff member threw a box of gloves toward the resident. The incident involved Resident #16, who had diagnoses including depression, chronic pain, and chronic obstructive pulmonary disease, and was dependent on staff for various activities of daily living. The resident had intact cognition with a BIMS score of 15 out of 15. The facility's policy on abuse, revised in August 2020, defined abuse as the willful infliction of injury or punishment resulting in harm or mental anguish, and stated a zero-tolerance approach. On the day of the incident, the facility was understaffed, and tensions were high among the staff. Staff F, a CNA, became frustrated with Resident #16's verbal aggression and threw a box of gloves at the resident, which hit the bed before making contact with the resident's head. The resident was not physically hurt but was upset by the incident. Multiple staff members, including Staff H, RN, and Staff N, CNA, witnessed the event and provided statements indicating that Staff F was overwhelmed and stressed due to the staffing situation and personal issues. Interviews with staff revealed that Staff F had been experiencing personal and professional stress, which contributed to her actions. The facility's administrator acknowledged the challenges in managing staff burnout and the need to monitor staff well-being. Despite the incident, Staff F was described as a good aide who generally provided good care, but the situation highlighted the impact of understaffing and stress on staff behavior and resident safety.
Failure to Separate Staff After Allegation of Abuse
Penalty
Summary
The facility failed to immediately separate a staff member from residents following an allegation of abuse involving a resident. The incident involved a resident with intact cognition, who was dependent on staff for various activities of daily living, including toileting hygiene and transferring. The resident was involved in an altercation with a Certified Nursing Assistant (CNA), who became frustrated and threw soapy washcloths and a box of gloves at the resident, with the gloves reportedly hitting the resident in the head. The facility's policy mandates the suspension of staff accused of abuse pending investigation, but this was not followed. The incident occurred during a time when the facility was understaffed, contributing to heightened stress levels among staff. The CNA involved in the incident admitted to being verbally abused by the resident and reacted by throwing a box of gloves, which she claimed did not hit the resident. However, other staff members and the resident's roommate provided accounts that suggested the gloves did make contact with the resident. Despite the altercation, the CNA continued to care for another resident before being asked to leave the facility. The facility's administrator acknowledged the failure to immediately separate the staff member from residents, as required by their policy. The administrator admitted that the CNA should have been removed from the facility immediately following the incident. The report highlights the facility's policy of zero tolerance for abuse and the expectation that residents should be free from abuse in their home environment.
Failure to Prime Insulin Pen and Follow Physician Orders
Penalty
Summary
The facility failed to properly prime an insulin pen before administering insulin to a resident. During a medication pass, an LPN administered insulin to a resident without priming the pen, which involves wasting 2 units before dialing the prescribed dosage. The LPN was unaware of the need to prime the pen, and the facility's diabetic management policy did not include instructions on priming insulin pens. The Director of Nursing confirmed that priming is necessary and mentioned plans for educating the nursing staff. Another deficiency involved the failure to follow physician orders for a resident who was readmitted after hospitalization. The resident, who was cognitively intact, had orders for insulin, glucose monitoring, and Vitamin D that were not transcribed correctly upon their return. The orders were only added four days later, and the resident did not recall missing any medications. The Director of Nursing acknowledged that the facility had several new admissions that week and only one floor nurse to double-check orders, which contributed to the oversight. The facility's policy requires that all physician orders be entered into the electronic medical record immediately and reviewed by a licensed nurse. However, the process was not followed correctly, leading to the delay in implementing the physician's orders for the resident. The Director of Nursing noted that the current pharmacy does not enter orders into the system, and there was a plan to have the pharmacy enter orders initially, with nurses double-checking them afterward.
Inadequate Bathing Care Due to Staffing Shortages
Penalty
Summary
The facility failed to provide adequate bathing care for two residents, Resident #32 and Resident #6, as observed during a survey. Resident #32, who has quadriplegia and is dependent on staff for all activities of daily living, reported receiving only two baths since admission, despite the facility's policy requiring at least two baths per week. Staff interviews revealed that the lack of sufficient staffing often led to missed baths, and Resident #32 was not known to refuse showers. The Director of Nursing confirmed that baths should be documented in the electronic health record, but inconsistencies in documentation and staffing shortages were noted. Similarly, Resident #6, who has paraplegia and multiple sclerosis, was assessed as needing staff assistance for bathing. The review of bath documentation showed that five scheduled baths were missed over two months. Resident #6 reported that the facility's staffing issues were the reason for missed showers, and staff confirmed that bath schedules were color-coded and required documentation. However, the completion of baths was inconsistent, particularly during night shifts, due to staffing shortages.
Failure to Act on Lab Results and Edema in Residents
Penalty
Summary
The facility failed to carry out necessary interventions for two residents, leading to deficiencies in care. Resident #17, who was cognitively intact and had multiple diagnoses including type 2 diabetes mellitus and coronary artery disease, had a lab result indicating a high white blood cell count, suggestive of a potential infection. The lab results were available on August 31, 2024, but the facility did not act on them until September 2, 2024, when the resident's condition worsened, showing signs of lethargy and fluctuating vitals. The delay in response resulted in the resident being sent to the emergency room for further evaluation and treatment, where they were diagnosed with acute cystitis. Resident #33, who had multiple sclerosis and muscle weakness, was identified with 2+ pitting edema in both lower legs and feet during skilled evaluations in June 2024. Despite the care plan directing staff to document and notify the physician about edema, there was no documentation of physician notification or any follow-up interventions related to the edema. This lack of action indicates a failure to adhere to the care plan and ensure timely medical intervention. Interviews with staff revealed lapses in communication and follow-up procedures. Staff D, an LPN, acknowledged that lab results should have been reviewed and acted upon promptly, but they were not addressed until after the weekend. The Director of Nursing admitted to being unaware of the missed lab results and the lack of documentation regarding Resident #33's edema. These oversights highlight deficiencies in the facility's processes for monitoring and responding to changes in residents' conditions.
Failure to Complete Dressing Changes as Ordered
Penalty
Summary
The facility failed to complete dressing changes as ordered for a resident with a stage 4 pressure ulcer on the coccyx/left buttock. The resident, who was cognitively intact and dependent on staff for various activities, had a care plan that included administering treatments as ordered and monitoring for effectiveness. Despite this, the Treatment Administration Records (TAR) indicated that a dressing change was missed on one occasion, and the resident reported that dressings were not changed on weekends, leading to the wound getting larger. Observations and interviews confirmed that dressing changes were not consistently performed as ordered, particularly over weekends. Staff interviews revealed that an LPN noticed the same dressing on the resident after returning from a weekend off, indicating that changes were not made during her absence. The LPN admitted to not always documenting these findings but reported them to the Director of Nursing (DON). The DON acknowledged being informed of the issue weeks prior and had completed re-education. The facility's policy on skin management did not address the completion of dressing changes as ordered, contributing to the deficiency.
Failure to Use Mechanical Lift for Resident Transfer
Penalty
Summary
The facility failed to adhere to the Care Plan for a resident who required mechanical lift assistance for transfers. The resident, who had diagnoses including depression, chronic pain, and chronic obstructive pulmonary disease, was assessed as dependent on staff for various activities of daily living, including transferring. The Care Plan specified the use of a mechanical lift with the assistance of two staff members for transfers. However, on one occasion, two CNAs transferred the resident without using the mechanical lift, resulting in all three individuals falling into the bed. The resident confirmed that this method of transfer occurred, although not frequently. Interviews with staff revealed that the mechanical lift was not used as required, and this was reported to the nurses. A Certified Medication Aide also heard about the improper transfer method and noted that the resident questioned why the lift was not used consistently. The facility's Administrator acknowledged that the resident was supposed to use the mechanical lift and stated that transferring without it was unacceptable. However, she was unaware of the incident until it was brought to her attention.
Failure to Provide Meals According to Resident Needs
Penalty
Summary
The facility failed to provide meals in accordance with the needs and preferences of a resident who required assistance with eating. The resident, who underwent dialysis on Mondays, Wednesdays, and Fridays, reported missing supper on one occasion and often not receiving food after returning from dialysis. The resident typically returned between 4-5 PM and ate in his room, requiring assistance from staff after they finished assisting in the dining room. However, due to insufficient staffing, the resident's meal was sometimes left at the nurses' station, and he would only receive a peanut butter and jelly sandwich after using his call light. Interviews with staff confirmed that the resident was occasionally forgotten for meals, and a CNA had to request a peanut butter and jelly sandwich for him. The Dietary Manager noted that the resident usually took a sandwich to dialysis and returned in time for dinner, but required assistance with eating. The manager expected CNAs to retrieve the resident's tray from the kitchen, but acknowledged that a former cook frequently forgot about the resident. The facility's undated food preparation policy directed staff to use portion-control methods to ensure correct quantities were served, but did not address the specific needs of residents requiring assistance with meals.
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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