Aspire Of Sutherland
Inspection history, citations, penalties and survey trends for this long-term care facility in Sutherland, Iowa.
- Location
- 506 East Fourth Street, Sutherland, Iowa 51058
- CMS Provider Number
- 165458
- Inspections on file
- 20
- Latest survey
- December 10, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aspire Of Sutherland during CMS and state inspections, most recent first.
The facility failed to manage bed hold agreements for residents transferred to hospitals, resulting in missing documentation and communication issues. A resident's bed hold agreement lacked a daily rate, another resident's family did not sign a declination, and two residents had no bed hold documents. The facility's policy on providing bed hold information during emergency transfers was not followed.
A LTC facility failed to administer prescribed medications to several residents due to unavailability, impacting their care. Residents with conditions such as schizophrenia, dementia, and hyponatremia did not receive medications like clozapine, sodium chloride, Allegra, and others as ordered. The facility did not notify physicians of these omissions, despite being aware of the medication shortages.
The facility staff did not follow the planned menu for a lunch meal, serving items that differed from the menu without prior approval. The Dietary Manager admitted to not seeking approval for menu substitutions, contrary to facility policy, which requires dietitian approval for any changes. The Administrator confirmed that the Dietary Manager should have obtained such approval.
The facility failed to maintain sanitary conditions in food service. The Dietary Manager (DM) did not perform hand hygiene upon entering the kitchen or when changing gloves. The DM handled a water pitcher and ice with soiled gloves, contrary to the facility's policy requiring handwashing before serving food and after handling soiled items. This was confirmed by the Administrator.
The facility did not provide a homelike environment during meal service as staff served meals on plastic trays and left them in front of residents, contrary to the facility's policy. The Administrator expected staff to place plates directly on the table, but this was not done.
The facility did not maintain licensed nursing coverage 24/7 during a fiscal quarter, affecting 19 residents. On multiple occasions, there was no licensed nurse on duty, contrary to the facility's assessment that required an RN or LPN for each shift. The Administrator was unable to locate the schedules for the months in question, despite the expectation for continuous nursing coverage.
The facility failed to update care plans for two residents, neglecting to address high-risk medications and dementia care. A resident with Bipolar Disorder was prescribed an opioid without care plan documentation on its usage or side effects. Another resident with moderate cognitive impairment and dementia experienced falls, but their care plan lacked dementia care strategies and post-fall interventions. The facility's policy requires comprehensive, individualized care plans, which were not adequately developed.
A facility failed to address dementia care for a resident with Non-Alzheimer's Dementia, anxiety disorder, and Bipolar Disorder. The resident's MDS assessment showed moderate cognitive impairment, but their care plan lacked dementia care information. The deficiency was confirmed by the DON, who acknowledged the oversight.
The facility failed to implement gradual dose reductions (GDR) and review psychotropic medications for three residents. A resident with intact cognition was on multiple psychotropic medications without GDR attempts, and another resident with dementia had a PRN order for Lorazepam without an end date. A third resident with moderate cognitive impairment was on Nefazodone without evaluation for the lowest dose. The Director of Nursing acknowledged the lapse in GDRs due to other priorities.
The facility did not ensure food was served at safe temperatures. The Dietary Manager pureed broccoli with cold milk, microwaved it briefly, and attempted to serve it at 123.6 F, below the required 135 F. The DM reheated it after a surveyor's prompt. The Administrator expected all foods to be served at safe temperatures.
The facility did not provide required dependent adult abuse training within six months of hire for a CNA. The personnel file for the CNA lacked evidence of the training, and the facility's policy did not specify the requirement for completing a two-hour training course. The Administrator acknowledged the absence of documentation and mentioned ongoing policy refinements.
A facility failed to protect residents from potential abuse after a CNA allegedly slapped a resident. Despite the allegation, the CNA was allowed to complete their shift, exposing residents to potential risk. The resident, with no cognitive impairment, reported the incident to staff, but the facility did not follow its abuse prevention policy, which requires immediate suspension of the accused staff member and prompt reporting to the DON and Administrator.
A resident with bipolar disorder, hypertension, and diabetes, who was cognitively intact, reported being slapped on the hands by a CNA when requesting a pop. The incident was confirmed through interviews with the resident and staff, revealing a failure to protect the resident from abuse. The facility's policy on abuse prevention was not followed, as the CNA continued to assist the resident after the incident, and there was a delay in reporting the incident to the DON.
A resident with bipolar disorder, hypertension, and diabetes reported being slapped by a CNA when asking for a pop. Despite the incident being known to several staff members, including the Administrator and DON, the facility failed to report the allegation to the state agency within the required 2-hour timeframe. The delay was partly due to the DON's unawareness of the reporting timeframe.
A facility failed to provide appropriate incontinence care for a resident with cerebral palsy, leading to a deficiency in preventing urinary tract infections. A CNA was observed using the same part of a disposable wipe multiple times during perineal care and did not perform hand hygiene after removing soiled gloves. The DON expected staff to use a clean part of the wipe for each wipe.
Deficiency in Bed Hold Documentation and Communication
Penalty
Summary
The facility failed to properly manage bed hold agreements for residents who were transferred to hospitals, resulting in deficiencies in documentation and communication. For Resident #2, the facility did not include a daily rate for the bed hold in the agreement, despite having a verbal order to sign for the Power of Attorney. Resident #5's family did not want to hold the bed during the resident's hospital stay, but there was no signed declination of the bed hold. Resident #7 also lacked a bed hold document for their hospitalization, indicating a pattern of missing documentation. Resident #10, who had moderate cognitive impairment, was sent to the hospital for pneumonia, but the facility did not have a bed hold for this hospitalization. The facility's policy required providing bed hold information during emergency transfers, but this was not adhered to. Interviews with the Administrator revealed an expectation for all residents to have a signed and complete bed hold agreement when transferred to the hospital, which was not met in these cases.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide prescribed medications as necessary care and services, impacting the residents' highest practical physical well-being. For Resident #21, who has diagnoses of paranoid schizophrenia and dementia, the nursing staff did not administer clozapine as ordered on multiple occasions. The medication was unavailable on specific dates, and there was no documentation indicating that the physician was notified of these omissions. The facility's administrator acknowledged that staff should manage medications to avoid missed doses and ensure physician notification for omitted doses. Resident #4, diagnosed with hyponatremia, did not receive sodium chloride tablets as prescribed from late November to early December due to the medication being out of stock. Despite multiple progress notes indicating the unavailability of the medication and the Director of Nursing's awareness, there was no documentation of physician notification regarding the missed doses. Interviews with the Director of Nursing and the Administrator confirmed that medications should be ordered and available at the facility as per the doctor's orders. For Resident #10, with diagnoses of Non-Alzheimer's Dementia, anxiety disorder, and Bipolar Disorder, Allegra Allergy tablets were not administered for several days due to unavailability. Similarly, Resident #13, with similar diagnoses, experienced multiple instances where prescribed medications, including Divalproex Sodium, Sertraline, Scopolamine transdermal patch, and Quetiapine fumarate, were not available. In both cases, there was no evidence of physician notification for the omitted medications. The facility's policy requires medications to be ordered in advance, but this was not adhered to, leading to the deficiencies noted.
Failure to Follow Planned Menu
Penalty
Summary
The facility staff failed to adhere to the planned menu for residents, as evidenced by a discrepancy observed during a lunch meal service. The planned menu for Week 1 Day 4 included lasagna, seasoned broccoli, a wheat roll with margarine, and strawberries and bananas. However, during the observation, the meal served consisted of lasagna, broccoli, and applesauce, deviating from the planned menu. An interview with the Dietary Manager revealed that she does not seek prior approval for making substitutions to the menu. The facility's policy requires that menus meet the nutritional needs of residents, be prepared in advance, and be followed, with any deviations noted and approved by a dietitian. An interview with the Administrator confirmed that the Dietary Manager should obtain approval from the dietitian before making any menu changes.
Failure to Maintain Sanitary Conditions in Food Service
Penalty
Summary
The facility failed to ensure that food was stored and prepared under sanitary conditions, as observed during a survey. The Dietary Manager (DM) entered the kitchen without performing hand hygiene and proceeded to apply gloves. With these gloves on, the DM opened and closed the refrigerator door, handled a water pitcher, and exited the kitchen. The DM returned with the same soiled gloves and an uncovered water pitcher full of ice, which was used to fill glasses. The DM continued to handle ice with the soiled gloves and did not perform hand hygiene when changing gloves during meal service. The facility's policy on food preparation and service, effective from October 2024, requires food service staff to wash their hands before serving food and after handling soiled items. However, the DM did not adhere to these guidelines, as confirmed by the Administrator during an interview. The DM's actions, including not washing hands upon entering the kitchen and during glove changes, directly contributed to the unsanitary conditions observed during the meal service.
Failure to Provide a Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment for its residents during meal service. Observations on December 4th revealed that staff served meals to residents in the dining room by placing plated meals, drinks, and silverware on plastic trays. These trays were then placed in front of the residents, and staff left the table without removing the trays. Once the residents finished eating, staff returned to remove the trays with the dishes still on them. This practice was contrary to the facility's policy, which emphasized minimizing characteristics that reflect a depersonalized, institutional setting. An interview with the Administrator confirmed that the expectation was for staff to remove the plate from the tray and set it directly on the table for the residents to eat their meals.
Failure to Provide 24/7 Licensed Nursing Coverage
Penalty
Summary
The facility failed to provide licensed nursing coverage 24 hours a day, as required, during the fiscal year 3rd quarter from April 1st through June 30th, 2024. Specifically, there was no licensed nursing coverage on several dates in April, May, and June. The facility reported a census of 19 residents during this period. An interview with the Administrator revealed that she could not locate the schedules for these months, although her expectation was for nursing staff to be scheduled 24/7. The facility's assessment document indicated that there should be one Director of Nursing (DON) Registered Nurse (RN) full-time on the day shift and either one RN or one Licensed Practical Nurse (LPN) for each shift, with the facility operating on 12-hour shifts, requiring two nurses per day not counting the DON.
Deficiencies in Care Plan Updates for High-Risk Medications and Dementia Care
Penalty
Summary
The facility failed to revise and update care plans for two residents, leading to deficiencies in addressing high-risk medications, dementia care, and post-fall interventions. Resident #9, who has diagnoses of amputation and Bipolar Disorder, was prescribed oxycodone-acetaminophen, an opioid medication, but the care plan did not include information on the usage of this medication or the side effects to monitor. This oversight indicates a lack of comprehensive care planning for managing high-risk medications. Resident #10, with a BIMS score indicating moderate cognitive impairment and a diagnosis of Non-Alzheimer's Dementia, experienced falls on two separate occasions. However, the care plan did not include dementia care strategies or interventions to prevent further falls. The facility's policy requires individualized, person-centered care plans with measurable objectives and time frames, but these were not adequately developed for the residents in question. The Director of Nursing acknowledged that the care plans should have included these critical elements.
Failure to Address Dementia Care in Resident's Care Plan
Penalty
Summary
The facility failed to address dementia care for a resident diagnosed with Non-Alzheimer's Dementia, anxiety disorder, and Bipolar Disorder. The Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 9, suggesting moderate cognitive impairment. Despite these diagnoses, the resident's care plan lacked information regarding dementia care. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the facility should have included dementia care in the care plan.
Failure to Implement Gradual Dose Reductions and Review Psychotropic Medications
Penalty
Summary
The facility failed to implement gradual dose reductions (GDR) and ensure proper review of psychotropic medications for three residents. Resident #4, with intact cognition, was on multiple psychotropic medications, including Paxil, Oxcarbazepine, Olanzapine, and Buspirone, without evidence of GDR attempts. Additionally, Resident #4 received Lorazepam as needed multiple times over several months without a review to ensure the necessity of continued use. Resident #14, who has renal insufficiency, Alzheimer's disease, and non-Alzheimer's dementia, had a PRN order for Lorazepam without an end date, and the medication was administered multiple times without a physician review. Resident #10, with moderate cognitive impairment and diagnoses of non-Alzheimer's dementia, anxiety disorder, and bipolar disorder, was on Nefazodone without documentation of an evaluation for the lowest possible dose. The facility's policy requires periodic reviews of medications and attempts at GDR for antipsychotic drugs unless clinically contraindicated. However, the Director of Nursing acknowledged that GDRs had not been completed due to other priorities, indicating a lapse in adherence to the facility's policy and federal guidelines.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at a safe and appropriate temperature. During an observation, the Dietary Manager (DM) was seen pureeing broccoli and adding cold milk to it. After pureeing, the DM microwaved the broccoli for 15 seconds, stirred it, and placed it on a tray to be served. When prompted by the surveyor, the DM checked the temperature of the pureed broccoli, which was 123.6 degrees Fahrenheit, below the required safe temperature. The facility's policy mandates that mechanically altered hot foods must remain above 135 F during preparation or be reheated to 165 F instantaneously. The DM acknowledged that the broccoli was not hot enough to serve and reheated it to a safe temperature before serving it to the resident. The Administrator confirmed the expectation that all foods should be served at safe and appropriate temperatures.
Failure to Provide Required Abuse Training for CNA
Penalty
Summary
The facility failed to provide dependent adult abuse training within six months of hire for one of the five employees reviewed, specifically a Certified Nursing Assistant (CNA) identified as Staff A. The personnel file for Staff A documented a hire date of March 25, 2024, but lacked evidence of the required training. The facility's policy on Freedom of Abuse, Neglect, and Exploitation, dated September 20, 2024, did not specify the requirement for each employee to complete an initial two-hour training course provided by the Iowa Department of Human Services within six months of hire. During an interview, the Administrator acknowledged the absence of documentation in Staff A's file and mentioned ongoing policy refinements due to recent organizational changes.
Failure to Protect Residents from Alleged Abuse
Penalty
Summary
The facility failed to protect residents from potential abuse after an allegation was made against a Certified Nurse Aide (CNA). On July 11, 2024, a nurse learned that a CNA allegedly slapped a resident on the hands. Despite this allegation, the facility allowed the CNA to complete their shift and continue working with other residents behind closed doors, which exposed residents to the potential risk of abuse. This situation resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The incident involved a resident with a diagnosis of bipolar disorder, hypertension, and diabetes mellitus, who had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The resident reported to multiple staff members that the CNA slapped her hands when she asked for a pop. Staff interviews revealed that the CNA continued to assist the resident after the incident, and the staff did not immediately report the allegation to the Director of Nursing (DON) or the Administrator. The facility's policy on abuse prevention requires that any staff member accused of abuse be suspended pending investigation. However, this protocol was not followed, as the CNA was allowed to finish their shift. The policy also mandates immediate reporting of abuse allegations to the charge nurse and subsequent notification of the Administrator and DON, which did not occur promptly in this case. The failure to adhere to these procedures contributed to the deficiency identified by the surveyors.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member. The incident involved a resident with diagnoses of bipolar disorder, hypertension, and diabetes mellitus, who had a BIMS score indicating no cognitive impairment. The resident reported that a CNA slapped her hands when she requested a pop. This incident was documented in the facility's incident report and progress notes. Interviews with the resident and various staff members, including an LPN, the Administrator, the DON, and other CNAs, confirmed the resident's account of the incident. The staff failed to implement appropriate interventions to protect the resident from abuse, as evidenced by the CNA continuing to assist the resident after the incident was reported. The facility's policy on abuse prevention outlines a zero-tolerance approach to abuse and emphasizes person-centered care. However, the staff did not adhere to these policies, as the CNA's actions were in direct conflict with the facility's standards. The DON acknowledged that the resident should have been allowed to have the pop, and the staff should have respected the resident's rights. The failure to immediately remove the CNA from the resident's care and the delay in reporting the incident to the DON further highlight the facility's inadequate response to the situation.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within the required 2-hour timeframe. The incident involved a resident with diagnoses of bipolar disorder, hypertension, and diabetes mellitus, who reported that a Certified Nursing Assistant (CNA) slapped her hand when she asked for a pop. The resident, who had no cognitive impairment, made the allegation to multiple staff members, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), but the report to the state agency was delayed. Interviews with staff revealed that the incident was known to several staff members, including the Administrator and the DON, on the morning following the alleged abuse. Despite this, the facility did not submit a self-report to the state agency until later that morning, beyond the 2-hour requirement. The facility's policy mandates immediate reporting of abuse allegations, but the DON was unaware of the specific timeframe for reporting, contributing to the delay.
Inappropriate Incontinence Care Leading to Deficiency
Penalty
Summary
The facility failed to provide complete and appropriate incontinence care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, who had diagnoses of cerebral palsy, abnormal posture, and muscle wasting and atrophy, was observed to be incontinent of bowel and bladder. During an observation, a Certified Nursing Assistant (CNA) performed perineal care on the resident but used the same part of a disposable wipe multiple times to clean feces from the anus to the buttocks area before switching to a clean part of the wipe. Additionally, the CNA did not perform hand hygiene after removing soiled gloves and before assisting with applying a clean incontinent brief. The Director of Nursing indicated that staff are expected to use a clean part of the wipe for each wipe during perineal care.
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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