Aspire Of Washington
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, Iowa.
- Location
- 601 E Polk St, Washington, Iowa 52353
- CMS Provider Number
- 165453
- Inspections on file
- 25
- Latest survey
- March 20, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Aspire Of Washington during CMS and state inspections, most recent first.
Three residents with significant risk factors for pressure ulcers did not receive consistent or timely interventions to prevent or treat existing wounds. One resident developed new heel wounds without proper offloading or physician notification, another with quadriplegia had a new buttock wound without a treatment order or repositioning program, and a third with paraplegia missed prescribed wound care due to unavailable medication. Documentation and care plan guidance were lacking in all cases.
A resident with paraplegia, depression, psychotic disorder, and limited upper extremity mobility, who was assessed as needing a smoking apron to prevent dropped ashes, was observed smoking without the required apron. Staff confirmed the resident was supposed to wear the apron and that staff were directed to enforce this intervention.
Two residents with cognitive impairment and complex medical histories experienced severe, unaddressed weight loss due to the facility's failure to consistently monitor weights, update care plans, notify physicians, and implement or document nutritional interventions. Staff interviews and record reviews revealed inconsistent practices in obtaining weights and providing supplements, as well as inadequate communication and follow-up regarding significant changes in condition.
A resident with dementia and a history of frequent falls suffered a fall resulting in fractures and ongoing severe pain. Staff failed to conduct adequate pain assessments, did not notify the physician in a timely manner, and did not implement or document effective pain management interventions, despite the resident's continued severe pain and changes in condition.
Multiple residents experienced delayed or inconsistent assessments for wounds, falls, and changes in condition, including unrecognized skin wounds, repeated unwitnessed falls, and untreated infections. Staff were often unaware of residents' conditions, documentation was incomplete, and communication lapses led to missed or delayed interventions, resulting in hospitalizations and worsening of injuries.
Multiple residents experienced repeated falls, some resulting in injuries, due to the facility's failure to thoroughly investigate incidents, perform timely root cause analysis, and implement or update effective interventions. Staff inconsistently used safety equipment such as gait belts during transfers, and care plans were not promptly revised to address changing needs. Despite frequent falls, interventions often relied on resident education, which was ineffective for those with cognitive impairment, and neurological assessments were not consistently performed after unwitnessed falls.
Three residents did not receive prescribed anti-seizure, antidepressant, and antianxiety medications due to failures in medication availability, pharmacy communication, and documentation. One resident missed several days of venlafaxine, leading to increased anxiety; another did not have rescue seizure medication available for a second seizure event; and a third missed multiple doses of anticonvulsants due to confusion over pharmacy orders and prescription status. Staff interviews and record reviews confirmed lapses in medication management and adherence to facility policy.
The facility failed to ensure effective administration by not promptly addressing abuse allegations, allowing staff to continue working after reports of verbal and physical mistreatment, and lacking documentation of these incidents. Additionally, staff were required to transport residents in a van with expired registration and unresolved safety issues, and there was no consistent process for bed holds during emergency transfers. The facility also failed to ensure proper narcotic counts and secure access to medication keys.
Multiple residents experienced undignified dining conditions and interactions, including a resident with cognitive impairment being addressed harshly by the DON, and several residents left without timely assistance during meals. One resident remained seated in soiled clothing for an extended period, and staff were not consistently present or positioned appropriately to assist residents with eating, as confirmed by staff interviews.
Nursing staff did not consistently start or restart neurological assessments after unwitnessed falls for a resident with frequent falls and multiple diagnoses. Despite facility policy requiring neuro checks after each unwitnessed fall, documentation showed missed, delayed, or incomplete assessments, and staff reported being instructed by the DON to continue existing neuro check schedules rather than initiate new ones for each fall.
A medication cart was found unlocked and unattended outside the nursing station, with drawers accessible and no staff present. An LPN left the cart unsecured while responding to a resident in pain, contrary to facility policy requiring all medication storage to be locked when not in use.
A resident's DNR status, as documented on a signed IPOST form, was not updated in the EMR or care plan, which continued to list full code interventions such as CPR and intubation. Staff interviews revealed that the Social Services Director could not update the EMR and relied on nursing staff, who had not made the necessary changes, resulting in a mismatch between the resident's documented wishes and the electronic records.
A resident who was dependent on staff for toileting and had intact cognition reported a missing monogrammed bed pad, which was documented in their inventory. Despite the resident notifying staff and a grievance being filed, the pad remained missing for several months, with staff and supervisors aware of the issue but unable to locate or promptly replace the item. The facility's policy required prompt investigation of missing property, but the resident continued to go without their personal pad while staff provided extra facility pads.
Two residents were admitted without a baseline care plan being completed within 48 hours, as required by facility policy. The DON acknowledged that the baseline care plans were not done on time, and the electronic health records confirmed the missing or overdue assessments. This resulted in a failure to promptly address the immediate needs of newly admitted residents.
Two residents did not have comprehensive care plans that addressed all their needs: one resident receiving antipsychotic medication lacked specific targeted behaviors in the care plan, and another resident with chronic pain did not have a pain management focus area included, despite ongoing pain and opioid use. The DON confirmed these omissions, which were not in line with facility policy requiring individualized, measurable care plans.
The facility did not update care plans for two residents to reflect current code status and oral care needs. One resident's care plan listed an incorrect code status despite physician orders and documentation indicating DNR, while another resident with quadriplegia and dental pain did not have oral care needs or dental interventions included in her care plan, and reported not receiving daily oral hygiene assistance.
A resident with a recent history of diabetic ketoacidosis was admitted with orders for insulin and frequent blood sugar checks, but the facility did not establish or follow clear parameters for physician notification of high blood sugar readings. Multiple blood sugar results exceeded 400 mg/dl, including several over 500 mg/dl, without documentation of physician notification, and staff confirmed that no specific notification guidelines were in place.
A resident with cognitive impairment, multiple fractures, and a neck brace requiring substantial assistance did not receive the required two baths or showers per week. Facility records lacked documentation of bathing for an entire month, and only two bed baths were recorded the following month. Multiple CNAs reported not providing or documenting baths, and the DON confirmed ongoing issues with both completion and documentation of showers, contrary to facility policy.
A resident with paraplegia and multiple risk factors for pressure ulcers did not receive consistent wound assessments as required by the care plan and facility policy. Documentation on several occasions failed to include all existing wounds, and the DON confirmed that weekly wound assessments and proper documentation were not routinely completed.
A resident with severe cognitive impairment and incontinence exhibited symptoms of a UTI, but staff failed to promptly obtain a physician-ordered urinalysis due to confusion, miscommunication, and concerns about the resident's combative behavior. The delay in collecting the urine sample and initiating antibiotic treatment resulted in a failure to provide timely care as required by facility policy.
Staff lacked the necessary training and guidance to address the behavioral health needs of two residents with complex mental health conditions, resulting in unmanaged behaviors such as skin picking and frequent verbal outbursts. Care plans and facility resources did not provide specific interventions, and staff interviews revealed uncertainty and insufficient education on managing these behaviors, contrary to facility policy and assessment requirements.
A resident with diabetes and moderately impaired cognition was administered Novolog insulin from a vial that had been opened for more than 28 days, exceeding the manufacturer's recommended discard period. An LPN administered the expired insulin and expressed uncertainty about the correct discard timeframe, while the DON confirmed the proper discard date. Facility policy and manufacturer instructions both required discarding opened insulin vials after 28 days, but this was not followed.
A resident with PTSD and depression was prescribed Seroquel for behavioral issues without adequate documentation of a mental health diagnosis, indication for use, or signed consent. The care plan lacked interventions for behaviors and monitoring of the psychotropic medication, and staff interviews confirmed the resident had not received required psychiatric services. The resident expressed concerns about side effects and lack of consent, while emergency department records recommended discontinuation of the medication, but the facility did not address these issues or document appropriate non-pharmacological interventions.
Two residents with significant physical disabilities and intact cognition did not receive routine or emergency dental services despite documented oral health issues and requests for care. Both residents reported not being offered dental appointments or assistance with oral hygiene, and staff interviews revealed confusion about the process for arranging dental care. Documentation confirmed neither resident was scheduled for in-house dental services, and both lacked necessary oral care supplies.
The facility experienced multiple repeat deficiencies, including harm-level citations for pressure ulcers, nutrition, assessment and intervention, and accidents/falls, as well as an Immediate Jeopardy citation for accidents/supervision. Despite having a QAPI plan and conducting audits and a PIP, the facility's process was ineffective in resolving ongoing issues, with staff interviews revealing challenges in clinical staffing, care plan implementation, and staff education.
A resident with severe cognitive impairment and a history of wandering eloped from a facility through an unalarmed door. The resident was found outside in a wheelchair, unable to move. Staff interviews revealed the door alarm was not activated, allowing the resident to exit unnoticed. The resident's care plan included interventions for elopement risk, but these were insufficient to prevent the incident.
The facility failed to maintain a clean and homelike environment, with observations of substances on floors and furniture, stained ceiling tiles, and missing tiles in a shower room. A resident confirmed the lack of deep cleaning, and staff acknowledged the difficulty in maintaining cleanliness and the need for repairs. The facility's policy requires a safe and clean environment, which was not met.
The facility failed to provide the required minimum of two baths or showers per week for several residents, including those with cognitive impairments and those requiring substantial assistance. Despite care plans specifying twice-weekly bathing, documentation showed missed baths, and residents confirmed receiving fewer baths than scheduled. Staff interviews revealed that the facility was understaffed, often with only two staff members available, making it challenging to complete all scheduled baths.
The facility failed to provide diverse, resident-centered activities, offering mainly bingo and music therapy, leading to resident boredom. Observations and staff interviews confirmed the limited activities, with residents often seen sitting idly. The administrator acknowledged the deficiency and aimed to expand the activity offerings.
The facility failed to provide sufficient nursing staff, resulting in delayed call light responses for three residents with intact cognition. Residents reported waiting over 15 minutes, with one resident waiting more than 25 minutes, causing distress. Staff interviews confirmed these delays, and staffing records showed inadequate CNA coverage on several shifts, despite a policy requiring prompt responses.
A resident with a stage IV pressure ulcer experienced worsening of the condition due to inadequate documentation and management. The ulcer increased in size and depth, with gaps in weekly wound assessments. The DON, responsible for multiple roles, struggled to maintain consistent documentation. The resident's care plan included wound evaluations and use of Hydrofera Blue, but frequent stooling affected treatment effectiveness. The facility's wound care policy was not consistently adhered to.
The facility failed to provide scheduled showers for four residents, including those with cognitive impairments and requiring assistance. One resident missed multiple showers due to lack of specific care plan instructions, while another's refusal to shower was not consistently followed up. A cognitively intact resident reported not having a shower for two weeks, and another with severe impairment had only one shower documented in a month. The lack of documentation and specific care plan instructions contributed to the deficiency.
A resident reported that meals were often lukewarm, and observations confirmed that food temperatures dropped significantly during transportation to rooms. Staff interviews revealed that room trays are delivered in open carts, contributing to the issue.
A resident with severe cognitive impairment was subjected to verbal abuse by a CNA, who used inappropriate language, profanity, and derogatory names. The resident confirmed these actions, which were corroborated by other staff members. The CNA had a history of using inappropriate language around residents.
A CNA at the facility failed to complete Dependent Adult Abuse Training within the required six months of employment, as mandated by facility policy. Despite multiple notifications from the Human Resources Director, including face-to-face encounters and text messages, the CNA did not complete the training. The facility's policy requires such training upon hire and annually, but the CNA's personnel file lacked documentation of completion, leading to a deficiency.
A facility failed to monitor and assess MASD for a resident with a history of heart failure and peripheral vascular disease. Despite the care plan requiring weekly skin assessments, none were performed between March and May, leading to ongoing issues with redness and pain. Staff reported treating the resident's skin folds with creams and powders, but the DON admitted to falling behind on assessments.
A facility failed to follow a physician's order for monthly catheter changes for a resident, who had a history of using an indwelling urinary catheter and a Moisture Associated Skin Damage (MASD) wound. The resident's care plan included catheter care instructions, but the Treatment Administration Record lacked orders for routine changes, increasing the risk of UTIs. The resident was unaware of a change schedule, and the DON confirmed no medical diagnosis justified the catheter's continued use, contrary to facility policy.
A resident with severe cognitive impairment and multiple health issues experienced significant weight loss due to the facility's failure to implement the Dietitian's recommendations for increased health shake frequency. Despite the care plan's goal to maintain stable nutritional status, the resident's weight decreased over 5% from March to May. Staff interviews revealed uncertainty about shake administration, and the facility's policy on addressing weight loss was not fully followed.
A resident with significant medical needs experienced a 23-minute delay in response to their call light, highlighting staffing shortages in the facility. Staff interviews revealed expectations to answer call lights within 10 to 15 minutes, but these are not consistently met due to insufficient staffing, with frequent call-ins and the DON often covering for absent nurses.
A facility failed to update the Preadmission Screening and Resident Review (PASRR) after a resident was prescribed antipsychotic medication for a new mental health condition. The resident, with a history of anoxic brain injury and depression, was given Quetiapine Fumarate for agitation without a Gradual Dose Reduction (GDR) attempt or documented contraindication. The facility did not follow its PASRR policy, which requires updates for significant changes in treatment needs.
A facility failed to properly administer insulin to a resident with diabetes, as an LPN did not prime the Novolog insulin pen needle and failed to document open and expiration dates on insulin pens. The Tresiba insulin was not administered as ordered, and the care plan lacked instructions for proper insulin pen use. Interviews revealed awareness of correct procedures, but these were not consistently followed.
The facility failed to track employee illnesses, including COVID-19 cases, and did not document water testing for Legionella. The DON, also the Infection Preventionist, did not monitor illnesses across all departments, despite a COVID-19 outbreak. The facility's policy did not include employee illness data collection. Additionally, there was no documentation of Legionella testing, and the facility lacked a comprehensive water management policy.
The facility failed to manage utility payments effectively, resulting in a scheduled disconnection of gas and electric services. Overdue balances and delayed payments led to multiple disconnection notices, with the issue only being resolved after intervention by the State Survey Agency. The facility Administrator was unaware of the disconnection notice until informed by the agency.
The facility failed to maintain a safe, functional, and sanitary environment, with a residential hallway remaining uninhabitable over a year after a sewer pipe backup. The hallway emitted a foul sewer smell, had heavily stained carpet, and several tiles in resident rooms were lifted, broken, or warped. Additionally, rooms were filled with unusable furniture and biohazard trash, and the facility grounds were disorderly. Extensive water damage was observed in a resident's room, with the resident stating that the damage had been present for several months. Staff interviews revealed that the previous Administrator prioritized remodeling other areas of the facility over addressing the sewer damage, and the current Administrator had only recently begun to address the issue.
A cognitively impaired resident was given an electric saw by the Maintenance Director, leading to an unsafe situation that required intervention by the DON. The resident's care plan required supervision due to mild cognitive impairment and a history of aggression related to dementia. Multiple staff members observed the incident, and the DON had to personally take the saw away from the resident, who became agitated.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement and document appropriate interventions to prevent and treat pressure ulcers for three residents with significant risk factors and existing wounds. One resident with diabetes, dementia, and Parkinson's disease developed an unstageable pressure ulcer on the right heel and later a blood blister on the left heel. Despite care plan notes and staff discussions about interventions such as slippers and offloading, there was no evidence of consistent implementation or documentation of these measures. The left heel wound was not reported to a physician or treated for over a week, and the care plan lacked specific guidance for pressure reduction on the heels. Another resident with quadriplegia and a history of pressure ulcers had a Stage 4 coccyx ulcer and developed a new open area on the buttocks. The care plan did not provide instructions for staff to assist with turning and repositioning, and there was no documentation of a turning and repositioning program. The resident's air mattress was set incorrectly, and a new wound was left without a treatment order or dressing for several days after discovery. A third resident with paraplegia and two unstageable pressure ulcers did not receive prescribed wound care due to the unavailability of Mupirocin ointment for at least two days. The care plan directed staff to carry out treatments as ordered, but medication administration notes confirmed the ointment was not available and not applied as required. These failures were observed and confirmed through record review, staff interviews, and direct observation.
Failure to Ensure Smoking Safety Interventions for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate safety interventions for a resident with paraplegia, depression, psychotic disorder, and limited range of motion in both upper extremities, who was assessed as requiring a smoking apron due to dropping ashes on himself. Despite care plan entries and safety assessments specifying the need for a smoking apron during smoking, the resident was observed smoking outside in the courtyard without wearing the required apron. Staff interviews confirmed that the resident was supposed to wear a smoking apron and that there was a list directing staff to ensure this intervention was followed.
Failure to Address Severe Weight Loss in Two Residents
Penalty
Summary
The facility failed to adequately address severe weight loss in two residents, both of whom were at high nutritional risk and had complex medical histories. One resident, who was cognitively impaired and had diagnoses including diabetes, schizoaffective disorder, and bulimia nervosa, experienced a severe weight loss of 12.6% over 180 days. Despite orders for weekly weights, the facility did not consistently obtain or document these weights, and there was no evidence that the physician was notified of the significant weight loss. The care plan did not reflect the actual weight loss, and interventions were not revised after the initial supplementation failed to maintain the resident's weight. Another resident, with moderately impaired cognition and a history of dementia, also experienced severe weight loss, losing 6.2% in 30 days, 7.9% in 90 days, and 13.1% in 180 days. The care plan for this resident did not address the actual severe weight loss, and there was a delay in obtaining a physician's order for nutritional supplements. Staff interviews revealed inconsistent practices regarding the provision and documentation of supplements, and weights were not obtained as frequently as ordered. The resident's intake was sporadic, and there were ongoing issues with diarrhea and dehydration, further complicating nutritional management. Throughout the period of deficiency, staff failed to consistently monitor, document, and communicate changes in the residents' conditions, including significant weight loss and poor intake. There was a lack of timely intervention and care plan updates, and the facility did not ensure that physician orders were implemented or that interventions were adjusted in response to ongoing weight loss. These failures were observed through record reviews, staff interviews, and direct observation of meal times and resident behaviors.
Removal Plan
- Facility re-weighed and reviewed for significant and/or severe weight loss for all current residents to implement interventions as needed.
- Facility reviewed medical records for presence of eating disorder and behavioral problems that could impact nutrition.
- Resident identified to have significant and/or severe weight loss reviewed by the Registered Dietitian for recommendations.
- Current residents with significant and/or severe weight loss had their physicians and responsible parties notified.
- Facility met with Medical Director to review residents' weight loss and facility corrective action.
- Interdisciplinary Team (IDT) re-educated on criteria for a significant and severe weight loss for 1 month, 3 months, and 6 months.
- Current staff educated on changes in resident condition to report, such as poor appetite, behavioral changes, difficulty eating, and/or vomiting.
Failure to Provide Effective Pain Management After Fall and Fractures
Penalty
Summary
A resident with a history of dementia, schizoaffective disorder, anxiety, depression, diabetes, and frequent falls experienced a fall resulting in limited range of motion and bruising/swelling to the right upper extremity. Over several days, documentation showed the resident exhibited severe pain, including moaning, groaning, and fear of walking, with staff noting non-verbal indicators of pain. Despite these symptoms, the facility did not conduct adequate follow-up pain assessments to determine the effectiveness of administered PRN Tylenol and Tramadol, nor did they notify the physician of the ongoing pain symptoms until several days later. An x-ray eventually revealed an acute, moderately displaced avulsion fracture of the right elbow, and a subsequent hospital visit identified a hip fracture. Upon the resident's return from the hospital, there was no evidence that the facility obtained or implemented new treatment orders. The resident continued to experience severe pain, frequently rating it as 10/10, and was observed crying out during transfers. Documentation did not indicate that alternative pharmacological or non-pharmacological interventions were attempted, nor was there evidence that pain management was effective during this period. The facility's records also lacked documentation of physician notification for multiple instances when the resident reported severe pain. The facility's care plans and policies required regular pain assessment, monitoring, and physician notification if interventions were unsuccessful or if there was a significant change in the resident's pain experience. However, these protocols were not followed, as evidenced by the lack of timely physician notification, insufficient pain reassessment, and failure to adjust pain management strategies despite ongoing severe pain and significant changes in the resident's condition.
Removal Plan
- Facility assessed current residents for unresolved pain, notified their doctors of unresolved pain, and updated Care Plans to include non-pharmacological interventions.
- Residents returning to facility from the Hospital, clinic, or emergency room (ER) visit to have orders reviewed upon arrival and ensure new orders are in place and updated.
- Facility plan to follow up with Primary Care Providers if a resident's pain continues and to monitor this weekly at Interdisciplinary (IDT) meetings.
- Licensed nurses and nursing administration re-educated on reporting changes in resident condition, including unresolved pain, and to review residents experiencing unresolved pain for root cause and implement intervention, including non-pharmacological interventions.
- Facility had meeting with Medical Director to review residents with unresolved pain and the facility corrective action.
Failure to Timely Assess and Intervene for Wounds, Falls, and Changes in Condition
Penalty
Summary
The facility failed to ensure timely, consistent, and accurate assessments for non-pressure skin wounds, changes in condition, and falls for multiple residents. In one case, a resident with severely impaired cognition had a chronic abdominal wound that was not consistently assessed or documented, with staff unaware of the wound's presence and weekly skin checks not completed as required. The Director of Nursing (DON) acknowledged that skin assessments were behind, and the facility administrator reported ongoing concerns about whether these assessments were being completed. Another resident with moderately impaired cognition and a history of functional bladder incontinence experienced multiple falls in a single day, with staff reporting up to 15-20 incidents of the resident putting herself on the floor. Despite these repeated events and a subsequent hospital evaluation revealing a complicated urinary tract infection (UTI) and delirium, there was a lack of documentation regarding urinary symptoms or pain prior to the hospital transfer. Incident reports were incomplete, and staff interviews revealed uncertainty about when to document falls or report changes in condition, with the DON not consistently notified of significant events or changes. A third resident with dementia, diabetes, and a history of falls suffered multiple unwitnessed falls, resulting in fractures to the right elbow and hip. Documentation showed delays in pain assessment, lack of timely physician notification, and inadequate follow-up after hospital discharge, including missing discharge instructions and failure to contact the hospital for care orders. Staff interviews confirmed that changes in the resident's pain and mobility were not promptly communicated or addressed. Another resident with intact cognition experienced frequent unwitnessed falls, changes in transfer status, and a UTI that progressed to acute kidney injury and bacteremia, with inconsistent neurological assessments and delayed physician notification. Staff reported confusion about fall protocols and communication lapses regarding changes in resident condition.
Failure to Prevent Accidents and Inadequate Supervision Resulting in Multiple Resident Falls and Injuries
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents. For one resident with a history of Parkinson's, dementia, seizures, and impaired cognition, there were repeated falls—eight between June and January—with four resulting in injuries such as scalp lacerations requiring staples or sutures and a hematoma. Documentation revealed that falls were often unwitnessed, and incident reports and progress notes were inconsistent or incomplete. Interventions to address the falls were delayed or inadequately implemented, with root cause analysis either not performed or not documented. The care plan was not updated in a timely manner to reflect new risks, such as increased incontinence or changes in mobility, and interventions addressing toileting needs were not added until months after repeated falls related to incontinence or bathroom needs. Another resident with severely impaired cognition required assistance with activities of daily living and transfers. Staff were observed attempting to transfer this resident without the use of a gait belt, despite care plan instructions and staff interviews indicating that a gait belt should be used for safety, especially given the resident's size and behavioral challenges. Staff interviews revealed inconsistent use of gait belts and a lack of clarity regarding proper transfer techniques, with some staff stating that a stand lift should be used instead of manual transfers with a gait belt. A third resident, who was independent with mobility but had a history of falls, experienced a high frequency of unwitnessed falls—twelve in a single month. The care plan interventions focused primarily on resident education and reminders to use the call light, despite repeated evidence that the resident was non-compliant with these instructions. Staff and the DON acknowledged that interventions had not been effective in preventing falls, and neurological assessments were not consistently restarted after each unwitnessed fall, contrary to protocol. Staff also reported that changes in the resident's condition, such as increased weakness and the need for more assistance, were not always promptly documented or communicated.
Failure to Ensure Availability and Administration of Critical Medications
Penalty
Summary
The facility failed to ensure that prescribed medications, including anti-seizure, antidepressant, and antianxiety drugs, were available and administered as ordered for three residents. In one case, a resident with diagnoses of post-traumatic stress disorder, moderate intellectual disability, and insomnia did not receive venlafaxine for several days due to the medication not being on hand. Documentation on the Medication Administration Record (MAR) repeatedly indicated the medication was unavailable, and there was a lack of corresponding nurse notes for several missed doses. The resident subsequently experienced increased anxiety, requiring a one-time dose of lorazepam. Pharmacy records confirmed that the facility did not communicate the need for the medication until several days after the initial order, resulting in a delay in administration. Another resident with a seizure disorder did not have the prescribed rescue medication, Nayzilam, available for a second witnessed seizure event on the same day. While the first seizure was treated with the available dose, the medication count reached zero afterward, and there was no documentation of administration for the second event. Controlled substance records showed discrepancies in the receipt and administration of Nayzilam, with doses received months prior but not signed out as administered. This resident subsequently experienced a fall and head laceration following the seizure activity. A third resident with a history of seizure disorder, schizoaffective disorder, and intermittent explosive disorder missed multiple doses of prescribed anticonvulsant medications, including Xcopri and rufinamide, due to issues with pharmacy communication and medication ordering. The MAR documented several consecutive days where these medications were not administered, marked as unavailable. Interviews with nursing staff and pharmacy personnel revealed confusion regarding medication discontinuation, refill requests, and the need for new prescriptions, particularly for controlled substances. Facility policy required timely administration and proper pharmacy coordination, but these processes were not followed, resulting in significant medication errors for all three residents.
Failure in Effective Administration and Resident Safety Protocols
Penalty
Summary
The facility failed to ensure effective administration in several key areas, resulting in multiple deficiencies. Staff interviews and record reviews revealed that allegations of abuse and mistreatment were not promptly or thoroughly addressed. Specifically, there were reports that a Certified Medication Aide (CMA) pulled a resident's hair and a Registered Nurse (RN) used derogatory language towards the same resident, who had severely impaired cognition. Staff members reported concerns about a particular CNA's verbal abuse towards multiple residents, including statements such as "shut up" and "get out of my face." These concerns were brought to the attention of the Administrator and DON multiple times, but the staff member continued to work, and there was a lack of documentation and follow-up on these allegations. The DON and Administrator acknowledged hearing concerns about staff tone but did not consistently recognize or document them as abuse allegations. The facility also failed to maintain current registration for a vehicle used to transport residents. Staff members reported driving the facility van with expired license tags, and some were aware of the issue but were still expected to use the vehicle. The Administrator and Senior Vice President of Operations confirmed that the registration had lapsed and that efforts to renew it were delayed due to missing documentation. Staff expressed discomfort and concern about being asked to drive the van with expired tags, and there were additional safety concerns regarding the van's back latch not securing properly during resident transport. Additionally, the facility did not have a consistent process in place for bed holds. Interviews with nursing staff and the DON revealed confusion and lack of adherence to the bed hold policy, particularly during emergency transfers. Staff were often unaware of the proper procedures or where to find the necessary paperwork, and the DON admitted that bed holds were not completed as often as required. The Administrator confirmed that bed hold forms were not consistently obtained from families during urgent transfers. Furthermore, there was a failure to ensure that narcotics were consistently counted at shift changes, and medication keys were not always accessible to qualified staff, as evidenced by an incident where a nurse was unable to access narcotics and the DON refused to assist with the count.
Failure to Ensure Dignified Dining and Resident Interactions
Penalty
Summary
The facility failed to ensure a dignified dining experience and respectful interactions for several residents, as evidenced by multiple observations and staff interviews. One resident with moderately impaired cognition and behavioral symptoms was addressed by the DON in a manner that did not align with the resident's care plan interventions, which called for calm, explanatory, and positive interactions. Instead, the DON spoke loudly and admonished the resident in front of others for attempting to enter another resident's room, without following the care plan's guidance for communication and redirection. During dining observations, five residents were seated together in an assisted dining area with only one staff member present. One resident, who was severely cognitively impaired and incontinent, was observed with a puddle of liquid under their wheelchair for an extended period while remaining at the table. Staff did not promptly address the situation, and the resident continued to sit in the soiled area until after the meal. Other residents with varying levels of cognitive impairment and assistance needs were present, and staff were not consistently available to provide supervision or assistance, as staff were observed leaving the dining area multiple times. Further observations in the main dining room revealed that residents requiring assistance with eating were not always attended to in a timely or appropriate manner. Staff were seen standing while assisting residents, which was later acknowledged by the Administrator as inappropriate. Residents were left without assistance, dropped utensils without staff response, and were not positioned properly at the table to eat. Staff interviews confirmed that staffing levels and assignments contributed to inadequate supervision and assistance during meals, and that staff were not always aware of best practices for providing dignified dining assistance.
Failure to Initiate Neurological Assessments After Unwitnessed Falls
Penalty
Summary
Nursing staff failed to consistently implement or restart neurological assessments after unwitnessed falls for a resident with a history of frequent falls. Clinical record review showed that the resident, who had intact cognition and diagnoses including schizophrenia, COPD, osteoarthritis, and a history of falling, experienced multiple unwitnessed falls over a short period. Despite facility policy requiring neurological checks after unwitnessed falls, documentation revealed that neurological assessments were either not initiated, delayed, or not restarted after subsequent unwitnessed falls. Incident reports and neurological flow sheets indicated that for several unwitnessed falls, there were either no vital sign or neurological checks documented, or the checks were started hours after the fall occurred. In some cases, the documentation was incomplete or unclear, with times and notations that were not explained. Staff interviews confirmed that nurses were instructed by the DON not to restart neurological assessments for each unwitnessed fall, but rather to continue the existing assessment schedule, even when multiple falls occurred in a day. The facility's policy directed staff to initiate neurological assessments after unwitnessed falls, especially when the resident could not verbalize what happened or if there were signs of head trauma. However, the DON acknowledged instructing staff to deviate from this policy due to the frequency of the resident's falls, and staff reported that fall notifications were limited to informing the DON, who would then notify the physician. This deviation from policy led to inconsistent and incomplete neurological monitoring following unwitnessed falls.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart was observed unlocked and unattended outside the nursing station, with no nursing staff present. The lock on the cart was not engaged, and the top two drawers could be opened without a key. This occurred when a nurse, after being informed that a resident was screaming in pain, left the cart unsecured while rushing to draw up medication. The facility's policy requires all compartments containing drugs and biologicals to be locked when not in use and not left unattended if open or accessible.
Failure to Update EMR to Reflect Resident's Advance Directive
Penalty
Summary
A deficiency occurred when a resident's code status in the electronic medical record (EMR) did not match the code status documented on their IPOST (Iowa Physician Orders for Scope of Treatment) form. The resident, who was cognitively intact as indicated by a perfect score on the Brief Interview for Mental Status, had a DNR (Do Not Resuscitate) order signed on the IPOST by both the resident and the physician. However, the EMR and care plan continued to reflect a full code status, including interventions for CPR, intubation, mechanical ventilation, and intensive care, despite the resident's documented wishes for DNR. Interviews with facility staff revealed a breakdown in communication and process for updating code status. The Social Services Director confirmed that she discusses code status with residents quarterly and during care conferences, and that changes are documented on a new IPOST form, which is then sent to the physician for signature and placed in the hard chart. However, she stated she is unable to update the EMR herself and relies on nursing staff to make the change. The DON acknowledged being behind on records and not having reviewed the files recently to ensure consistency between the IPOST and the EMR. This failure resulted in the resident's advance directive not being accurately reflected in the EMR and care plan.
Failure to Promptly Replace Missing Resident Personal Property
Penalty
Summary
A resident with intact cognition, dependent on staff for toileting hygiene and occasionally incontinent of bladder, reported a missing monogrammed bed pad that was documented in their personal inventory. The resident stated the pad, which had their name on it, had been missing for several months and that they had informed laundry staff, who acknowledged difficulty in finding a replacement with the same material. The facility's grievance form confirmed the missing pad and noted ongoing efforts to locate it, but the item remained unaccounted for. Multiple staff interviews revealed that the missing pad was known to both housekeeping and supervisory staff, who had searched for it and believed it may have been accidentally discarded. The DON reported challenges in sourcing a replacement due to the pad's size, and the administrator acknowledged the resident's request for replacement, despite facility policy stating they were not responsible for personal items. The facility's personal property policy required prompt investigation of missing items, but the pad remained unreplaced for an extended period, with staff continuing to search and the resident using extra facility-provided pads in the interim.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for two residents. For one resident, the clinical record showed no baseline care plan was completed within the required timeframe, with the electronic health record indicating the assessment was 39 days overdue. The DON confirmed during an interview that she had not completed the baseline care plans, including for this resident, and stated that while nurses completed some paperwork, she typically tried to do the baseline care plan the next day to learn more about the residents. For another resident, the admission summary indicated the resident was admitted from a local hospital, but the clinical record lacked a baseline care plan within 48 hours. The electronic health record did not list the required assessment. The DON stated in an interview that she attempted to complete the care plans and had a worksheet for nurses to check off new admissions, but the baseline care plan was not completed as required. Facility policy mandates that a baseline care plan be developed within 48 hours of admission to address immediate needs, but this was not followed for these two residents.
Failure to Include Targeted Behaviors and Pain Management in Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans included targeted behaviors for the use of antipsychotic medication and pain management for two residents. For one resident with moderately impaired cognition and diagnoses including major depressive disorder with psychotic symptoms and unspecified dementia, the care plan referenced the use of psychotropic medications but did not specify the targeted behaviors for which the antipsychotic was prescribed. The care plan interventions were general, such as administering medication as ordered, monitoring for side effects, and consulting with pharmacy and the physician, but lacked individualized, measurable objectives related to the resident's specific behavioral symptoms. For another resident with intact cognition and diagnoses of paraplegia, chronic pain syndrome, and polyneuropathy, the care plan did not include a focus area addressing chronic pain, despite documentation of frequent pain affecting sleep and the use of both scheduled and as-needed opioid pain medications. Physician orders and assessments indicated ongoing pain management needs, but the care plan did not reflect these needs or outline specific interventions or goals for pain control. Interviews with the Director of Nursing confirmed that targeted behaviors for antipsychotic use and a pain care plan were not included for the respective residents. Facility policy required individualized, person-centered care plans with measurable objectives and time frames based on thorough assessments, but these requirements were not met for the two residents reviewed.
Failure to Update Care Plans for Code Status and Oral Care Needs
Penalty
Summary
The facility failed to revise and update care plans to reflect current and accurate information for two residents. For one resident with moderately impaired cognition, the care plan listed the code status as 'Full Code--Attempt Resuscitation (CPR)', while both a physician order and an IPOST form indicated the resident was 'Do Not Resuscitate' (DNR) and to allow natural death. The Director of Nursing (DON) acknowledged that social work should update the care plan to reflect the correct code status, but this had not been done. For another resident with quadriplegia and intact cognition, the care plan did not address oral care needs despite documentation of a dental issue causing pain and the resident's report of not receiving daily assistance with oral hygiene. The resident stated she had requested to see a dentist due to a painful cavity but had not been asked about dental care needs at admission or since. The DON indicated uncertainty about which residents were on the dental provider list and stated that in-house provider visits were not included in the care plan. The facility's policy requires care plans to be individualized, comprehensive, and updated as residents' conditions change, but this was not followed in these cases.
Failure to Establish and Follow Blood Sugar Monitoring Parameters for Diabetic Resident
Penalty
Summary
The facility failed to ensure that blood sugar monitoring and physician notification parameters were in place and followed for a resident recently admitted after hospitalization for diabetic ketoacidosis. The resident, who had a history of diabetes mellitus and had been hospitalized for uncontrolled blood sugars, was admitted with orders for insulin administration and blood sugar checks four times daily. The care plan included monitoring for signs and symptoms of hyperglycemia and hypoglycemia, but the insulin orders lacked specific instructions for when to notify the physician in the event of abnormal blood sugar readings. Clinical record review showed multiple instances where the resident's blood sugar readings exceeded 400 mg/dl, with several readings over 500 mg/dl, yet there was no documentation that the physician was notified of these critical values. Staff interviews confirmed that there were no established parameters for physician notification, and the DON acknowledged that such parameters had not been implemented. The medical record did not contain evidence of physician notification for blood sugars greater than 500 mg/dl, despite repeated occurrences.
Failure to Provide and Document Required Bathing for Dependent Resident
Penalty
Summary
The facility failed to provide at least two baths or showers per week for a resident who required substantial to maximal assistance with bathing and other activities of daily living. The resident, who had a history of fractures, impaired balance, falls, seizures, and intellectual disability, was admitted with a neck brace that could not be removed. According to the care plan, the resident was to receive assistance from one to two staff members for showering twice a week and as necessary. However, clinical record review, shower calendars, and skin sheets revealed a lack of documentation for any bath or shower during the entire month of December, and only two bed baths were documented in January. Interviews with multiple CNAs indicated that several staff members had not provided the resident with a bath or shower, and there was confusion regarding the resident's bathing schedule and documentation procedures. The resident reported not having showered since receiving the neck collar and only possibly receiving a bed bath. The DON acknowledged ongoing issues with completing showers due to staffing shortages and confirmed the absence of required documentation for December and only minimal documentation for January. Facility policy required staff to document the date, time, and details of each shower or bath, including any skin assessments and reasons for refusal, but this was not consistently followed. The failure to provide and document regular bathing for the resident constituted a deficiency in meeting the resident's needs for activities of daily living.
Failure to Consistently Assess and Document Pressure Ulcers
Penalty
Summary
The facility failed to perform consistent wound assessments for a resident with significant risk factors for pressure ulcers. The resident had intact cognition but was dependent for mobility and transfers, with medical diagnoses including traumatic spinal cord dysfunction, paraplegia, and polyneuropathy. The resident was admitted with an unstageable pressure ulcer and had physician orders for specific wound care interventions. The care plan required weekly documentation of wound measurements and characteristics for each area of skin breakdown. Clinical record review showed that skin check documentation on three separate dates included only one pressure ulcer, despite the presence of two wounds on the buttocks. The documentation lacked complete assessment details as required by the care plan and facility policy. During an interview, the DON confirmed that wound assessments were not being completed routinely and that nurses were not consistently using the required documentation tools. The facility policy directed weekly skin evaluations, which were not consistently performed.
Failure to Timely Treat Urinary Tract Infection Due to Delayed Urinalysis
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely treatment of a urinary tract infection (UTI) for a resident with a history of cerebrovascular accident and vascular dementia, who was always incontinent of urine and bowel. The resident's care plan included monitoring for UTI symptoms and interventions for incontinence care. Over several days, documentation showed the resident exhibited increased behaviors, refused care, and had changes in urination, including reports of pain and burning. A physician order was obtained for a urinalysis (UA) with possible catheterization, but the order was not promptly carried out, and there was a lack of documentation explaining the delay or the use of a code indicating the order was not completed. Staff interviews revealed confusion and miscommunication regarding the execution of the UA order. The Certified Medication Aide and Registered Nurse were unsure why the UA was not obtained, and the DON instructed staff not to perform the catheterization due to the resident's combative behavior, expressing concern for staff safety and the resident's well-being. The order for the UA was not passed on or followed up in a timely manner, and the resident continued to display symptoms consistent with a UTI, including foul-smelling urine and agitation during care. Eventually, the UA was collected and sent, and antibiotic treatment was initiated after a significant delay. Facility policy required obtaining a urine culture for symptomatic residents prior to starting antibiotics, using catheterization if necessary for those unable to provide a clean catch sample. The failure to promptly obtain the ordered UA and initiate treatment resulted in a delay in addressing the resident's UTI symptoms, as evidenced by the clinical record, staff interviews, and facility documentation.
Failure to Ensure Staff Competency in Behavioral Health Care
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents, as evidenced by the care of two residents with mental health and behavioral issues. For one resident with a history of dementia, psychotic and mood disturbances, and anxiety, staff interviews revealed ongoing skin-picking behaviors that resulted in open wounds. Despite this, the resident's care plan did not specifically address interventions for picking behaviors, and several staff members were either unaware of the presence of wounds or unsure of how to manage the behavior effectively. Documentation showed that the wound was chronic and repeatedly aggravated by the resident's picking, with staff acknowledging the behavior but lacking clear, consistent interventions or guidance on how to address it. Another resident with diagnoses including PTSD, mild intellectual disabilities, and schizoaffective disorder exhibited delusions, verbal outbursts, and frequent crying or screaming. Staff interviews indicated a lack of training and guidance on how to manage these behaviors, with several staff members expressing uncertainty or stating they had not received education on handling residents with mental health issues. The care plan included general interventions, but staff reported not knowing how to address the resident's specific behaviors in a positive or effective way. Some staff attempted redirection or used activities like coloring, but there was no consistent or documented approach, and staff expressed a need for more education and resources. The facility's own policies and facility assessment required competency-based education for staff to address behavioral health needs, including those related to trauma, PTSD, and other mental disorders. However, interviews with staff and leadership revealed that resources such as a behavior book were incomplete, lacked specific guidance on triggers and interventions, and were not fully integrated into staff workflows. The absence of a kardex or other accessible documentation further contributed to staff uncertainty, and the facility had not ensured that all staff were adequately trained or equipped to meet the behavioral health needs of its residents as required.
Expired Insulin Administered Due to Failure to Follow 28-Day Discard Policy
Penalty
Summary
A deficiency occurred when staff failed to ensure that a medication, specifically Novolog insulin, was not administered past the manufacturer's recommended discard date of 28 days after opening. A resident with moderately impaired cognition and a diagnosis of diabetes mellitus was observed receiving 8 units of Novolog insulin from a vial that had been opened on 12/11/24 and labeled with a discard date of 1/9/25. However, the insulin was administered on 1/14/25, which was five days past the labeled discard date. The LPN administering the medication confirmed the expiration date on the vial and expressed uncertainty about the correct discard timeframe, citing varying durations such as 28, 31, or 42 days depending on facility practices. The resident's care plan included administration of diabetic medication as ordered, with monitoring and documentation of side effects and effectiveness. Physician orders specified scheduled and sliding scale doses of Novolog insulin. The facility's policy and the manufacturer's instructions both required opened insulin vials to be discarded after 28 days. Despite this, the expired insulin was administered, and both the LPN and the DON acknowledged the correct discard date during interviews. The incident was identified through observation, record review, and staff interviews.
Failure to Ensure Drug Regimen Free from Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not obtaining a mental health diagnosis, not providing adequate indication for the use of a psychotropic medication, not responding to a request for an evaluation for a dose reduction, not care planning for behavioral concerns, and not obtaining a signed consent for the use of Seroquel. The resident in question had diagnoses of PTSD and depression and was prescribed Seroquel 25 mg three times daily for behaviors, but the care plan lacked documentation for behavioral interventions and monitoring related to Seroquel administration. The Treatment Administration Record and behavior notes documented multiple behavioral incidents, including aggression, agitation, and removal of ostomy bags, but there was no evidence of a comprehensive behavioral care plan or consistent psychiatric follow-up. Interviews with staff revealed that the resident had refused psychiatric services and did not sign consent forms for psychotropic medication. The DON and social services staff confirmed that the resident had not seen psychiatric services since admission, despite a PASRR indicating the need for specialized services. Staff also reported that the Seroquel was ordered for behaviors such as breaking a window, cursing, and aggression, but there was no documentation of non-pharmacological interventions or a clear rationale for continued use of the medication at the prescribed dose. The facility’s policy required a diagnosis, indication, and evaluation prior to starting psychotropic medications, as well as informed consent and care planning, none of which were adequately documented in this case. The resident expressed concerns about the side effects of Seroquel, particularly its impact on blood pressure, and reported feeling forced to take the medication without proper evaluation or consent. Emergency department records corroborated the resident’s concerns, noting that the medication was being used primarily for sedation and recommending its discontinuation to improve compliance with other medications. Despite these concerns and recommendations, the facility did not adequately address the resident’s requests for dose reduction or alternative interventions, nor did it ensure proper documentation and consent for the use of psychotropic medication.
Failure to Provide or Arrange Dental Services for Dependent Residents
Penalty
Summary
The facility failed to provide or obtain routine and emergency dental services for two residents with significant physical disabilities and intact cognition. For one resident with quadriplegia, clinical documentation showed the presence of a cavity or broken tooth and a total dependence on staff for oral care, yet the care plan lacked specific interventions for oral health needs. The resident reported requesting dental care for a painful tooth but was not offered a dental appointment, nor was she provided assistance with oral hygiene or access to basic supplies like a toothbrush. Her roommate also lacked oral care supplies. Staff documentation indicated oral care was performed, but the resident's statements and lack of supplies contradicted this. For another resident with paraplegia and malnutrition, records indicated oral health problems such as cavities and broken teeth, with care plans instructing staff to monitor and report dental issues. However, the resident reported not being offered dental care or assistance in arranging appointments, despite expressing willingness to receive such care. Interviews with staff revealed a lack of awareness regarding the residents' needs and the process for arranging dental services. Documentation confirmed that neither resident was on the list to be seen by the in-house dental provider, and there was confusion among staff about responsibility for coordinating dental care.
Repeat Deficiencies Due to Ineffective QAPI Process
Penalty
Summary
The facility failed to maintain an effective QAPI (Quality Assurance and Performance Improvement) process to address previously identified quality deficiencies, resulting in multiple repeat deficiencies over several surveys within an eight-month period. Deficiencies included harm-level citations for treatment of pressure ulcers, nutrition, assessment and intervention, and accidents/falls, as well as no actual harm citations for dignity, activities of daily living (ADLs), urinary tract infection (UTI) or urinary catheter, nutrition, and unnecessary drug use. An Immediate Jeopardy (IJ) citation was also issued for accidents/supervision. The facility's QAPI plan outlined a process for monitoring and evaluating care, but repeat deficiencies indicated that the process was not effective in resolving ongoing issues. During staff interviews, the Administrator acknowledged challenges in the clinical department, including the need for better staffing and support for the DON, who was described as overwhelmed. The Administrator was not fully aware of previous nutrition issues and believed improvements had been made in areas such as bathing and skin assessments based on audits and a Performance Improvement Project (PIP). However, documentation and interviews revealed that care plans and staff education on care plans, particularly regarding skin assessments and wound care, required further attention. The QAPI committee's responsibilities included prioritizing concerns and conducting root cause analyses, but the recurrence of deficiencies suggested these actions were insufficient or not fully implemented.
Resident Elopement Due to Unsupervised Exit
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a severely cognitively impaired resident who was identified as high risk for elopement. The resident, who had a history of wandering and elopement, exited the building through an unlocked and unalarmed front door. The resident self-propelled her wheelchair out the front door and through the parking lot to the back of the building at an unknown time. Staff discovered the resident at approximately 6:30 AM when they exited the building for a break. The resident was found with a wheel of her wheelchair stuck on the edge of the concrete, unable to move. The incident was classified as an Immediate Jeopardy to the health and safety of the residents at the facility. The resident, who had a severely impaired cognition score of 2 out of 15 on the Brief Interview for Mental Status exam, had a history of delusions and required substantial assistance for mobility. She had experienced two or more falls since the last assessment and was taking medications in high-risk drug classes. Interviews with staff revealed that the front door alarm was not activated, allowing the resident to exit without setting off the alarm system. Staff members were unaware of the resident's absence until she was found outside. The facility's elopement management policy was not effectively implemented, as the door alarms were not properly monitored, and staff did not ensure the alarms were activated after use. The resident's care plan included interventions for elopement risk, but these were not sufficient to prevent the incident.
Removal Plan
- Resident #1 was assessed immediately by the licensed nurse; no injuries noted.
- Medical Director notified of elopement by the Director of Nursing.
- Resident #1 responsible party notified by the Director of Nursing.
- The Medical Director notified for medication review due to increased behaviors; a medication increase for Seroquel was ordered for stabilization.
- All exit door alarms will be monitored every 2 hours to ensure alarms are armed and functioning appropriately. If a failure is noted, the door will be monitored by staff 24 hours a day/7 days per week until the alarm is functioning properly. The elopement monitoring tool will be updated daily during the morning meeting by the Administrator and or Director of Nursing.
- The dining room has 24 hours per day, 7 days per week monitoring by staff to ensure no failures occur. Monitoring will occur until the Magnetic Locks with keypads are installed by the vendor, when the vendor equipment is available. In the absence of a scheduled staff member, the Administrator and/or Director of Nursing will monitor the dining room door. Department heads will be scheduled in two-hour increments during the day shift and then nursing staff will be assigned to monitor from 6 PM to 6 AM daily.
- 100% review of all current residents identified as elopement risk was completed by the Licensed Nurses and/or Social Service Director. 11 out of 36 residents were identified for elopement risk. Each resident identified as an elopement risk was placed in an updated elopement binder at each nursing station of the facility.
- The facility Elopement Policy was reviewed and included the safety of resident, unplanned absence, comprehensively assess/evaluate the resident for the risk for elopement, assist the Interdisciplinary Team to develop a plan and provide a resident with a safe and secure environment, utilize individualized interventions to maintain a resident's safety within the facility by the Senior President of Clinical Services.
- In-service education for staff regarding the Elopement Policy was initiated by the Nursing Home Administrator and or Director of Nursing and is ongoing with new staff and agency staff that included the elopement assessment, Implementation, Elopement risk, Evaluation and evaluating the outcomes with staff.
- No staff shall work until they have completed in-service education regarding Elopement. Staff will be in-serviced and educated on Elopement including safety of residents, unplanned absence, comprehensively assess/evaluate the resident for the risk for elopement, assist the Interdisciplinary Team to develop a plan and provide a resident with a safe and secure environment, utilize individualized interventions to maintain a resident's safety within the facility standardized process to evaluate effectiveness of interventions through care planning process and make changes as necessary to elopement, analyze trends and validate sustained improvement by the Administrator. The Administrator will monitor elopement education needs weekly to ensure staff is in-serviced prior to working schedule shift.
- Newly hired staff will be in-serviced on elopement with regards to unsafe wandering, identifying and reporting Risk to Elopement or Actual Elopement, Investigation process, unplanned absence of a resident, assist with developing a plan and provide a resident with a safe and secure environment, utilize individualized interventions to maintain a resident's safety within the facility, evaluate the effectiveness of interventions through care planning process and make elopement changes as necessary, trend and validate sustained outcomes.
- Ad hoc Quality Assurance Performance Improvement meeting was conducted regarding Elopement Management. The Administrator and Director of Nursing will monitor for patterns and trends and report to Quality Assurance Performance Improvement Committee weekly for 4 weeks and quarterly, thereafter. Quality Assurance Performance Improvement Committee will evaluate the effectiveness of the above plan and will adjust the plan based on outcomes identified.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, hazard-free, and homelike environment for its residents, as observed during a survey. Specific observations included a dried white substance on the metal bottom bar of an over-bedside tray table, multiple round black substances on the floor around the base of a recliner, and a brownish-blackish substance around the base of a toilet in a resident's room. Additionally, brown stains were noted on ceiling tiles in the 600 hallway, and the shower room had reddish, brownish, and black substances on the floor and in the corners, with missing tiles underneath the sink. The 300 hallway had brownish stains on the ceiling tile above the men's bathroom, and the 400 hallway had a brown vinyl baseboard coming off the walls. Interviews with residents and staff confirmed the need for a deep cleaning and repairs. A resident confirmed that their room had not been deeply cleaned and described the bathroom as disgusting. The Maintenance Supervisor acknowledged the difficulty in keeping up with cleaning and the need for ceiling tile replacement and deep cleaning. The Administrator also confirmed the need for deep cleaning and repair, particularly in the 600 hallway shower room, which requires a complete remodel. The facility's policy, dated August 2021, states that residents should be provided with a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Failure to Provide Scheduled Baths Due to Staffing Shortages
Penalty
Summary
The facility failed to provide the required minimum of two baths or showers per week for four out of seven residents reviewed. Resident #1, diagnosed with diabetes mellitus, thyroid disorder, non-Alzheimer dementia, anxiety, and depression, required substantial to maximal assistance with bathing. The resident's care plan specified assistance twice weekly, but records showed missed baths in September and October 2024. Resident #2, with severe cognitive impairment and dependent on staff for bathing, also missed scheduled baths in the same months. Despite the care plan's instructions to reapproach and notify a nurse if the resident refused a shower, documentation was lacking. Resident #4, with intact cognition but requiring setup assistance for bathing, confirmed receiving only one bath per week, contrary to the care plan. Similarly, Resident #6, who required substantial assistance, reported receiving only one bath per week. Staff interviews revealed that the facility was understaffed, often with only two staff members available, making it challenging to complete all scheduled baths. The facility's policy required at least two showers per week, but due to staffing shortages, this standard was not met.
Lack of Resident-Centered Activities
Penalty
Summary
The facility failed to implement resident-centered activities for four of the seven residents reviewed, despite having a policy in place that mandates an ongoing program of activities designed to meet the interests and well-being of each resident. Residents with intact cognition expressed dissatisfaction with the limited activities available, which primarily consisted of bingo and music therapy. Interviews with residents revealed that they often spent time in their rooms watching television due to a lack of engaging activities. Observations confirmed the lack of diverse activities, with residents often seen sitting with their eyes closed in front of a television. Staff interviews corroborated the residents' complaints, with a Licensed Practical Nurse acknowledging the limited activities and the resulting boredom among residents. The facility's administrator also confirmed the inadequacy of the activity calendar and expressed a goal to expand the activities offered to residents.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Three residents with intact cognition reported significant delays in call light responses, with wait times exceeding 15 minutes. Resident #3 experienced delays over 15 minutes, Resident #5 reported similar delays once or twice in the past week, and Resident #6 expressed distress over waiting more than 25 minutes. These delays were corroborated by staff interviews, where CNAs and an LPN confirmed that call lights were not answered within the expected 15-minute timeframe. The facility's staffing records revealed insufficient CNA coverage on several shifts, contributing to the delayed response times. On specific dates, shifts were understaffed with only one or two CNAs scheduled, despite a resident census of 37. The facility's policy, updated in August 2023, mandates that call lights be answered as soon as practicable, with emergency calls requiring a response within one minute. However, the facility did not meet these guidelines, as confirmed by staff and the administrator during interviews.
Failure to Prevent Worsening of Pressure Ulcer
Penalty
Summary
The facility failed to prevent a pressure ulcer from worsening in a resident who was admitted with a stage IV pressure ulcer to the sacral region. The resident, who was cognitively intact and dependent on staff for various activities, had a pressure ulcer that increased in size and depth over time. Initial assessments documented the ulcer as 1 cm in length and 0.5 cm in width, with no depth recorded. However, subsequent evaluations showed the ulcer growing larger and deeper, reaching a depth of 3.5 cm by early May. The facility's care plan for the resident included documenting the wound's location, drainage, and other characteristics, as well as evaluating the wound for size, depth, and signs of infection. Despite these directives, there were gaps in the documentation of weekly wound assessments, with several weeks missing records. Interviews with staff revealed that the Director of Nursing (DON), who was also responsible for multiple roles including wound care, was unable to consistently document the wound assessments due to her workload. The resident's wound care involved the use of Hydrofera Blue, but frequent stooling compromised the effectiveness of the dressing. Staff interviews indicated that the resident did not have an air mattress for the first few days after admission, which may have contributed to the ulcer's progression. The DON acknowledged the challenges in managing the wound care documentation and noted that the wound had initially appeared gray but later showed signs of improvement, although it had grown deeper. The facility's policy on wound care emphasized the importance of complete documentation and regular review of wound progress, which was not consistently followed in this case.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers or baths for four residents, leading to a deficiency in care. Resident #4, who is cognitively impaired and requires assistance with showers, was not given showers on multiple scheduled days across February, March, and May. The care plan for Resident #4 did not specify the need for showers on Mondays and Thursdays, contributing to the oversight. Resident #5, also cognitively impaired and requiring substantial assistance, missed several scheduled showers in February, April, and May. Although the care plan noted the resident's tendency to refuse showers and instructed staff to re-approach and notify the nurse, the documentation showed missed showers without consistent follow-up. Resident #7, who is cognitively intact but requires setup or cleanup assistance, reported not having a shower for two weeks. The facility's records showed no documentation of showers for Resident #7 in February and incomplete records in March and April. Resident #16, with severe cognitive impairment and requiring substantial assistance, had only one shower documented between mid-April and mid-May, despite being scheduled for twice-weekly showers. The care plan lacked specific instructions on bathing frequency, contributing to the deficiency.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to serve food at a palatable temperature for one lunch meal observed and for one resident interviewed. Resident #2, who is cognitively intact with a BIMS of 15 and has diagnoses including a Stage IV Pressure Ulcer, Neurogenic Bladder, and Quadriplegia, reported that meals were often lukewarm and not as warm as desired. The resident is dependent on staff for various activities of daily living, including eating. Interviews with staff revealed that room trays are delivered in carts open on all sides, with only a hard plastic dome covering the plates, which may contribute to the food cooling down before reaching the residents. During an observation on 05/07/24, the temperatures of food served from the main kitchen were within the expected range, but by the time the food was transported to the resident's room, the temperatures had dropped significantly below the expected range of 135 to 145 degrees Fahrenheit. The Dietary Manager confirmed the expectation for hot food temperatures, indicating a failure in maintaining these standards during the transportation process. This deficiency was identified through observations, record reviews, and interviews with both residents and staff.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by staff using inappropriate language and derogatory remarks towards a resident with severe cognitive impairment. The resident, who had a BIMS score of 6 out of 15 and required substantial assistance with daily activities, was subjected to verbal abuse by a Certified Nursing Assistant (CNA). The CNA was heard making loud statements about the resident going to jail and used profanity and derogatory names towards the resident on multiple occasions. The incident was observed and reported by another CNA, who confirmed that the abusive CNA had cursed at the resident, called him names, and placed his cell phone out of reach. The resident confirmed these allegations, stating that the CNA had pushed him, hit him on the forehead, and used profanity and derogatory names. The resident expressed that these actions made him feel bad and did not want to be around the abusive CNA. Interviews with other staff members corroborated the resident's claims, revealing that the abusive CNA had a history of using inappropriate language and profanity around residents. The Director of Nursing (DON) and other staff members acknowledged that the CNA had been educated on the inappropriateness of such behavior but had not received any disciplinary action prior to the suspension following the reported incident.
Failure to Complete Dependent Adult Abuse Training
Penalty
Summary
The facility failed to ensure the timely completion of Dependent Adult Abuse Training for a Certified Nursing Assistant (CNA), identified as Staff A, within the first six months of employment. This deficiency was identified during a review of employee personnel files and facility policies. Staff A, who began employment on October 31, 2023, had not completed the required training by the time of the survey. The facility's policy mandates that abuse identification, reporting, prevention, screening, investigation, and protection training occur upon hire and annually thereafter. However, Staff A's personnel file lacked documentation of the completion of this training. The Human Resources Director confirmed that Staff A had been repeatedly notified about the training requirement through face-to-face encounters and text messages, which included a link to access the training. Despite these notifications, Staff A did not complete the training and often responded dismissively to the reminders. The facility's policy also requires a review of personnel files and in-service attendance for implicated staff during abuse investigations, but this process was not effectively implemented in Staff A's case, leading to the deficiency.
Failure to Monitor and Assess Moisture Associated Skin Damage
Penalty
Summary
The facility failed to monitor and assess Moisture Associated Skin Damage (MASD) for a resident following the identification of skin impairment. The resident, who was dependent on staff assistance for transfers and at risk for pressure injuries, had a history of heart failure, peripheral vascular disease, and other conditions that increased the risk of skin breakdown. The care plan for the resident included interventions to avoid excessive moisture and complete weekly full body skin assessments. However, the facility did not perform any skin assessments between March 12, 2024, and May 14, 2024, despite the resident having ongoing issues with redness and episodic pain in the perineal region. Interviews with staff revealed that the resident had redness and open areas in skin folds, which were treated with creams and powders. The Director of Nursing (DON) admitted to falling behind on the weekly skin assessments, confirming that the last assessment was completed on March 12, 2024. The facility's policy required weekly head-to-toe body audits by a licensed nurse, but this was not adhered to, leading to a deficiency in monitoring and assessing the resident's skin condition.
Failure to Implement Physician's Order for Catheter Changes
Penalty
Summary
The facility failed to implement a physician's order for monthly indwelling catheter changes for a resident, leading to a deficiency in care. The resident, who had a history of using an indwelling urinary catheter, was found to have a Moisture Associated Skin Damage (MASD) wound and other diagnoses such as a high Body Mass Index (BMI), muscle wasting, and depression. The care plan for the resident included instructions for catheter care, but the Treatment Administration Record (TAR) for May 2024 did not include orders for routine catheter changes, which are necessary to reduce the risk of urinary tract infections (UTIs) due to bacterial buildup on the catheter tubing. Interviews and records revealed that the resident was unaware of a schedule for catheter changes, and the Director of Nursing (DON) confirmed that there was no medical diagnosis justifying the continued use of the indwelling catheter. The facility's policy on incontinent management stated that catheters should not be used without valid medical justification and should be discontinued when not clinically warranted. Despite this, the resident continued to use the catheter without a related diagnosis, and the facility did not adhere to the physician's order for monthly catheter changes.
Failure to Implement Dietitian's Recommendations Leads to Resident Weight Loss
Penalty
Summary
The facility failed to implement the Dietitian's recommendations to prevent weight loss for a resident with severe cognitive impairment and multiple diagnoses, including non-Alzheimer's dementia, stroke, and malnutrition. The resident's care plan, revised in April 2023, aimed to maintain stable nutritional status without significant weight loss. Despite the Dietitian's recommendation on February 19, 2024, to provide a health shake twice daily, and later to increase it to three times daily, the facility did not update the Electronic Health Record (EHR) to reflect the increased frequency. The Medication Administration Record (MAR) showed the health shake was only given twice daily until April 19, 2024, when it was increased to three times daily. However, the resident experienced a significant weight loss of over 5% from March to May 2024. The Nursing Progress Notes lacked documentation of provider or responsible party notification regarding the resident's weight loss between March 15 and May 5, 2024. Staff interviews revealed uncertainty about the frequency of health shake administration, and observations noted the resident pocketing food and not eating as before. The Director of Nursing (DON) acknowledged that the update for health shake frequency might have been missed and stated that the resident's provider was informed of the weight loss, leading to a Speech Therapy evaluation. The facility's policy on Nutrition and Weight Management required several steps to address significant weight loss, including re-weighting, dietitian consultation, and care plan updates, which were not fully implemented in this case.
Delayed Response to Resident's Call Light Due to Staffing Shortages
Penalty
Summary
The facility failed to respond to a resident's call light in a timely manner, as observed during a survey. The resident, who is cognitively intact with a BIMS score of 15, has a Stage IV Pressure Ulcer, Neurogenic Bladder, and Quadriplegia, and is dependent on staff for various activities of daily living. On the day of observation, the resident's call light was on for 23 minutes before being addressed by staff. During this time, a housekeeper and a CNA interacted with the resident but did not turn off the call light or address the resident's needs promptly. Interviews with staff revealed that there is an expectation to answer call lights within 10 to 15 minutes, but this is not consistently met due to staffing shortages. Staff reported that the facility is often understaffed, with fewer aides and nurses than needed, leading to delays in responding to residents' needs. The Director of Nursing confirmed the staffing issues, noting frequent call-ins and the need for the DON to work on the floor due to nurse shortages.
Failure to Update PASRR After Antipsychotic Medication Initiation
Penalty
Summary
The facility failed to submit a Preadmission Screening and Resident Review (PASRR) following the addition of antipsychotic medication for a new mental health condition in one of the residents. This oversight was identified during a review of the clinical records and facility policies. The resident in question, who had a history of anoxic brain injury, cerebrovascular accident, and depression, was prescribed Quetiapine Fumarate for agitation without an attempted Gradual Dose Reduction (GDR) or documented clinical contraindication for such an attempt. The resident's care plan noted the use of psychotropic medications and aimed to prevent drug-related complications, yet the facility did not update the PASRR when the antipsychotic medication was initiated. Additionally, the facility's PASRR policy, which requires updates when there is a significant change in a resident's treatment needs, was not followed. The resident's PASRR, completed prior to admission, did not require a level 2 screening as no serious mental illness was identified at that time. However, after the resident was diagnosed with unspecified psychosis and prescribed antipsychotic medication, the facility did not submit a new PASRR. The facility's administrator confirmed the oversight and noted that the Social Services Director would be educated on PASRR submission requirements.
Failure to Properly Administer Insulin and Document Insulin Pen Usage
Penalty
Summary
The facility failed to properly administer insulin to a resident, identified as Resident #26, who was cognitively intact and diagnosed with Diabetes Mellitus, COPD, and an open wound. During a medication pass, an LPN did not prime the needle of the Novolog insulin pen before administration and failed to write the open and expiration dates on three insulin pens. The Tresiba insulin was not administered as ordered, and there was no documentation indicating that the physician was notified of the missed dose. The facility's medication administration records did not include instructions to prime the needles of insulin pens prior to administration. The facility's care plan for Resident #26 did not instruct staff to prime the insulin pen needles or to document the open and expiration dates of the pens. Interviews with the LPN and the Director of Nursing revealed that they were aware of the proper procedures for insulin pen use, including priming the needle and dating the pens. However, these practices were not consistently followed, and the Director of Nursing acknowledged that there was a widespread issue among nurses with dating opened items.
Inadequate Infection Surveillance and Legionella Testing
Penalty
Summary
The facility failed to maintain adequate surveillance data on employee illnesses and did not document results for testing the water for Legionella. The Director of Nursing (DON), who also serves as the Infection Preventionist, did not track employee illnesses, including COVID-19 cases, across all departments. This oversight occurred despite a COVID-19 outbreak in January 2024, where eight residents and four staff members tested positive. The DON believed her responsibility was limited to the nursing department and did not document surveillance data, even though she completed the CDC Nursing Home Infection Preventionist Training Course in February 2020. The facility's Infection Surveillance Policy, last revised in September 2023, did not include provisions for collecting data on employee illnesses, focusing solely on residents. Additionally, the facility lacked documentation of water testing for Legionella. The Administrator could not provide records of testing results, only presenting two cartridges used for testing, dated February and April 2023. The facility did not have a policy addressing measures to prevent Legionella growth or a system to monitor and intervene when control limits were not met. The CDC guidelines for developing a water management program were not fully implemented, as the facility did not have a comprehensive policy to manage and document water testing and control measures.
Failure to Manage Utility Payments
Penalty
Summary
The facility failed to effectively manage the payment of its utility bills, resulting in a scheduled disconnection of gas and electric services. The review of the facility's utility bills revealed significant overdue balances, with a bill dated 2/15/24 showing a total of $10,109.56 due by 3/6/24, and a subsequent bill dated 3/15/24 showing a total of $9,475.55 due by 4/4/24. Staff interviews indicated that the facility had received multiple collection calls from the utility company, and the previous Administrator had informed staff that the utilities might be shut off due to nonpayment. The utility company confirmed that the facility was past due and had initiated the disconnection process on 3/20/24, which was only abated after the State Survey Agency intervened and prompted immediate payment from the corporation. The facility had received disconnection notices for 5 of the last 6 months due to failure to pay the required balances by the due dates. The facility Administrator stated she was unaware of any disconnection notice or scheduled disconnection due to nonpayment until informed by the State Survey Agency. The utility company reported that an automated phone call was placed on 3/20/24 to notify the facility of the required payment to avoid service disruption, followed by another call on 3/21/24. Despite these notifications, the facility continued to struggle with timely payments, leading to the risk of disconnection. The facility's utility bills were mailed to the corporation's address in Florida, and the facility had a history of delayed payments, which contributed to the ongoing issue of potential utility disconnections.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment for residents, staff, and the public. Observations revealed that a residential hallway remained uninhabitable over a year after a sewer pipe backed up, causing extensive damage to the floor and surrounding resident rooms. The hallway emitted a foul sewer smell, had heavily stained carpet, and several tiles in resident rooms were lifted, broken, or warped. Additionally, rooms were filled with unusable furniture and biohazard trash, contributing to the unsanitary conditions. The facility grounds were also found to be disorderly, with a broken toilet and biohazard trash scattered around the property. Extensive water damage was observed in a resident's room, with the resident stating that the damage had been present for several months. Staff interviews revealed that the previous Administrator prioritized remodeling other areas of the facility over addressing the sewer damage, and the current Administrator had only recently begun to address the issue. The facility corporation President and Regional President of Operations were unaware of the extent of the damages and the lack of a maintenance policy. The facility utilized the TELS system for maintenance operations, but it was evident that the system was not effectively managing the required repairs.
Failure to Ensure Resident Safety by Providing Hazardous Tool
Penalty
Summary
The facility failed to ensure resident safety when the Maintenance Director provided a cognitively impaired resident with an electric reciprocating saw to use outside the facility. The resident, who had diagnoses including hypertension, peripheral vascular disease, anxiety, psychotic disorder, Alzheimer's disease, and dementia, scored 12 out of 15 on the BIMS cognitive assessment, indicating mild cognitive impairment. The resident's care plan required staff supervision to ensure safety and included specific interventions for managing cognitive impairment and aggression related to dementia. Despite these precautions, the Maintenance Director gave the resident a hazardous tool, leading to an unsafe situation that required intervention by the Director of Nursing (DON). Staff interviews revealed that the Maintenance Director's actions were observed by multiple staff members, including a CNA and an LPN, who reported the incident to the DON. The DON had to intervene personally to take the saw away from the resident, who became agitated and threw the saw to the ground while it was still on. The resident confirmed the incident during an interview, expressing a preference for gardening and working outside but recalling the event with agitation. The DON acknowledged that residents should not have access to hazardous machinery and expressed confusion over the Maintenance Director's decision to provide the saw to the resident.
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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