Avoca Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Avoca, Iowa.
- Location
- 610 East York Street, Avoca, Iowa 51521
- CMS Provider Number
- 165294
- Inspections on file
- 26
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Avoca Specialty Care during CMS and state inspections, most recent first.
A resident with diabetes, hypertension, and hypothyroidism did not receive physician-ordered laboratory tests, including A1c and other labs, as required. Despite clear orders documented in the EMR and care plan, staff failed to ensure the labs were completed, and there was no documentation of the required testing after a certain point. The DON and Administrator confirmed the orders were not followed, and the facility's policy did not specifically address adherence to physician orders.
Two residents who required assistance with bathing did not consistently receive scheduled baths or showers, and there was a lack of documentation showing that staff offered or encouraged bathing as required. One resident did not receive any baths during their stay, while another experienced gaps in bathing and inconsistent documentation, with staff and DON interviews confirming these deficiencies.
Multiple residents did not receive scheduled baths or timely toileting assistance due to staffing shortages and inconsistent follow-up, with documentation showing missed or unoffered baths, long wait times for call lights, and poor hygiene observed among residents. Staff interviews and resident council notes confirmed that care was often delayed or omitted, and facility procedures for documenting refusals and notifying supervisors were not consistently followed.
The facility did not maintain sufficient nursing staff to meet residents' needs, resulting in missed or delayed baths, long call light response times, and inadequate assistance with toileting and personal hygiene. Two residents reported infrequent bathing and extended waits for help, leading to accidents and discomfort. Staff interviews and documentation confirmed that care tasks were often postponed or missed due to staffing shortages, and support staff observed residents left in soiled conditions after night shifts.
The facility did not maintain complete and accurate records for several residents, including missing documentation of bathing refusals, behavioral incidents, and attempts to arrange telehealth appointments. Staff interviews confirmed that required documentation was often omitted, and care plans were not updated in a timely manner to reflect changes in resident needs.
A resident who required assistance for toileting and had no cognitive impairment was left waiting for help and subjected to dismissive treatment by two CNAs, with concerns not reported within the required timeframe. The LPN who witnessed the incident delayed reporting, and the facility's investigation was incomplete, lacking follow-up interviews with the resident, her roommate, and all relevant staff, as well as proper documentation of the resident's psychosocial status.
A resident who required substantial assistance for toileting was subjected to neglectful and condescending treatment by two CNAs, who delayed responding to call lights and refused to assist the resident to the bathroom without a mechanical lift. An LPN witnessed these actions but did not report the concerns to management or authorities within the required two-hour timeframe, resulting in a delayed report to the State Agency. Facility policy required immediate reporting of suspected abuse or neglect, but the process was not followed.
A facility failed to thoroughly investigate allegations of staff misconduct and possible mistreatment of a resident who required substantial assistance for toileting. The investigation lacked follow-up interviews with the resident after her report of being left without help, did not include input from her roommate or all relevant staff, and omitted documentation of psychosocial checks, contrary to facility policy.
A resident who became dependent on a mechanical lift for transfers did not have this change reflected in her care plan, despite staff using the lift and communicating the change verbally. The care plan and Kardex continued to indicate assistance of two staff without specifying the use of the EZ stand, and staff reported that care plans were not updated promptly, relying instead on verbal communication and the EHR.
A resident with moderate cognitive impairment and dementia, who required substantial assistance for toileting, repeatedly refused staff help and became verbally aggressive when told a mechanical lift was needed. Staff, including CNAs and an LPN, did not attempt further individualized interventions beyond documenting the refusals, despite facility policy requiring non-pharmacological approaches for problematic behaviors. The care plan directed calm communication, but no additional strategies were used when the resident continued to refuse care.
Surveyors found expired medications and supplies, including multiple bottles of Aspirin and a syringe, in the medication room and on medication carts. An LPN and a CMA were present during these findings, and staff interviews revealed inconsistent practices for checking expiration dates. The DON stated that both pharmacy and staff are responsible for reviewing items as they are stored, in accordance with facility policy.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses for several residents. A resident with quadriplegia and another with Multiple Sclerosis reported significant delays, with staff confirming that insufficient staffing contributed to these issues. Another resident experienced long wait times affecting family visits, and a resident dependent on staff for transfers waited over an hour for assistance. The DON acknowledged the expectation for call lights to be answered within 15 minutes but noted the absence of a formal policy.
A facility failed to accurately assess a resident's use of an anticoagulant during the MDS observation period. The resident was documented as using an anticoagulant, but was only taking baby Aspirin, an anti-platelet. The MDS coordinator misidentified Aspirin as an anticoagulant due to the resident's history of blood clots, leading to incorrect coding on the MDS. The facility's policy requires accurate resident assessments, which was not followed.
A resident with quadriplegia and an enteral tube did not receive proper infection prevention measures during medication administration. A nurse failed to wear a gown, as required by the facility's enhanced barrier precautions policy for residents with indwelling medical devices. The Director of Nursing confirmed the expectation for appropriate PPE use, indicating a lapse in infection control protocols.
The facility failed to provide adequate bathing and personal hygiene care for several residents due to staffing shortages. Residents reported missed baths and inadequate grooming, with staff confirming that baths were not consistently completed. The Director of Nursing acknowledged the issue, stating that residents should receive baths twice a week unless they refuse, and that nail trimming should occur during bath times.
The facility experienced significant staffing shortages, resulting in delayed responses to resident call lights, with some waiting up to 40 minutes. Residents and staff reported consistent issues with insufficient staffing, particularly during evening and weekend shifts, affecting the quality of care. The DON acknowledged staffing was based on census rather than resident acuity, contributing to the problem.
The facility failed to maintain adequate kitchen staffing, leading to untrained staff from other departments, such as CNAs and LPNs, stepping in to perform dietary tasks. Residents expressed dissatisfaction with meal services, and staff reported being asked to assist in the kitchen without proper training or certification. The dietary manager's absence and the facility's inability to retain kitchen staff contributed to this issue.
The facility was found to have deficiencies in food storage and handling practices. Hamburger meat was improperly stored, and moldy green peppers were found in the cooler. A dietary aide used the same gloves for handling both dirty and clean dishes, violating infection control practices. Additionally, a staff member handled ready-to-eat food with bare hands, contrary to facility policy.
The facility failed to maintain resident dignity and respect, as evidenced by an LPN's inappropriate behavior towards multiple residents. A resident reported the LPN's dismissive and unhelpful attitude, while another overheard her using profane language and speaking negatively about residents. Staff interviews confirmed the LPN's frequent use of profanity and complaints about residents, impacting the residents' sense of dignity. The facility's policies emphasize treating residents with kindness and respect, which was not upheld in these instances.
A resident with mild cognitive impairment and identified as an elopement risk left the facility unsupervised. Staff failed to follow proper procedures when responding to a door alarm, assuming another staff member had triggered it. The resident was later found and returned without injury, but the incident highlighted inconsistencies in staff understanding and execution of elopement protocols.
The facility failed to dispose of room trays with leftover food in a timely manner, as trays were found in residents' rooms long after meals. A dietary aide noted finding dishes after weekends, and a resident reported uncollected dishes from breakfast and lunch. The DON acknowledged shared responsibility for tray collection but noted policy ambiguity regarding timing.
The facility failed to ensure proper storage and use of vape pens for two residents. One resident had vape pens in his room without documentation of his ability to smoke safely, while another used a THC and CBD vape pen indoors, contrary to the facility's smoking policy. The policy requires smoking evaluations and prohibits smoking inside, but the resident was found with a vape pen and THC gummies in her room, which were later removed.
Failure to Complete Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to follow physician orders for laboratory testing for one resident with diagnoses including diabetes mellitus, hypertension, and hypothyroidism. The resident's care plan and electronic medical record (EMR) included multiple physician orders for A1c and other labs to be completed at specified intervals. Despite these orders, there was no documentation that the required labs were completed after a certain date. The Director of Nursing (DON) confirmed that orders for A1c checks and other labs were not carried out as directed, and this was further corroborated by a review of the EMR and staff interviews. The deficiency was identified through interviews, record reviews, and policy review, which revealed that staff did not consistently enter or complete lab orders in the EMR as required. The DON and Administrator both stated their expectations that staff should enter and complete orders as directed, but the lack of documentation and follow-through resulted in missed laboratory testing for the resident. The facility's policy on medication and treatment orders did not specifically address the requirement to follow physician orders, contributing to the failure to ensure labs were completed as ordered.
Failure to Provide Scheduled Bathing Assistance and Inadequate Documentation
Penalty
Summary
The facility failed to provide scheduled bathing assistance to two residents who required help with activities of daily living. One resident, with diagnoses including cancer, anemia, atrial fibrillation, hypertension, heart failure, and end stage renal disease, was admitted and discharged within a week and required assistance from one staff member for bathing. Despite being scheduled for sponge baths or showers twice weekly, there was no documentation that this resident received any baths during their stay, nor were there records of attempts to offer or encourage bathing. Another resident, with moderately impaired cognition and diagnoses of hypertension, peripheral vascular disease, diabetes mellitus, and a history of stroke, required substantial assistance for bathing. This resident was scheduled for baths or showers twice weekly, but records showed inconsistent documentation between electronic and paper forms. There was a period of several days without a documented bath, and no evidence of additional attempts to offer or encourage bathing after a refusal. Staff interviews confirmed that documentation practices were inconsistent and that required follow-up after refusals was not always performed or recorded.
Failure to Provide Scheduled Bathing and Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure that residents received baths at the frequency required by their care plans, specifically twice a week or as requested, for six residents reviewed. Documentation revealed multiple instances where baths were not offered or documented as being offered, particularly after a resident refused or when 'not applicable' was recorded. In several cases, there were extended periods where no bath was documented, and residents reported receiving baths far less frequently than scheduled. Some residents also reported not being offered alternative hygiene measures, such as washcloths for freshening up, when baths were missed. Additionally, the facility failed to provide timely toileting assistance for two residents. Residents described long wait times for call lights to be answered, sometimes up to an hour, resulting in incontinence episodes and discomfort. Staff interviews confirmed that staffing shortages contributed to delays in providing care, including both bathing and toileting assistance. Staff also reported that when there were not enough CNAs on shift, baths would be postponed or missed entirely, and documentation practices included marking 'not applicable' when baths were not completed due to staffing issues. Resident council notes and grievances further corroborated concerns about inadequate bathing and nail care. Staff interviews revealed inconsistent practices regarding documentation and follow-up when residents refused baths, as well as reliance on the next shift to complete missed baths. Observations of residents confirmed poor hygiene, such as long and dirty fingernails and strong odors, further evidencing the lack of consistent care. Facility policy required documentation of refusals and notification of supervisors, but these procedures were not consistently followed.
Failure to Provide Adequate Nursing Staff for Resident Care Needs
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the daily needs of all residents, as evidenced by multiple observations, interviews, and documentation reviews. Residents reported not receiving scheduled baths, experiencing long wait times for call light responses, and not receiving timely assistance with toileting needs. For example, one resident with a left below-knee amputation and significant assistance needs stated he was only receiving one bath per week instead of the scheduled two, and sometimes went two weeks without a shower. He also described waiting up to 45 minutes for help during the day and having accidents due to delayed assistance, particularly at night when staff would turn off his call light while he was asleep without providing care. Another resident, who was dependent on staff for bathing and dressing, reported receiving a bath only once a month, despite preferring weekly baths. He also described long waits for call light responses, sometimes up to an hour, resulting in accidents while waiting for help with toileting. Observations confirmed that his fingernails were long and dirty, and a strong odor was present during care, indicating lapses in personal hygiene assistance. Staff interviews corroborated these issues, with CNAs and LPNs acknowledging that baths and other care tasks were often missed or delayed due to insufficient staffing, especially when only one or two CNAs were present on a shift. Resident council notes and grievance forms further documented ongoing concerns about inadequate staffing, missed baths, and long call light response times. Staff described a routine of passing missed baths to the next shift and documenting 'NA' when baths were not completed due to staffing shortages. The Director of Nursing confirmed that staffing levels were often insufficient, leading to delays or missed care, and that baths would be postponed when there were not enough staff members available. Housekeeping and laundry staff also reported finding residents soaked in bed in the mornings, particularly after night shifts with minimal staffing.
Failure to Maintain Complete and Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for all seven residents reviewed, as evidenced by missing or incomplete documentation regarding bathing, behavioral incidents, and telehealth appointment attempts. For multiple residents, scheduled bath or shower documentation frequently indicated refusals or was marked as 'not applicable,' yet corresponding progress notes lacked explanations for these refusals or the reasons for the 'not applicable' entries. Facility policy required that refusals and interventions be documented, but this was not consistently done. Additionally, staff interviews confirmed that documentation of refusals and interventions was often omitted, and supervisors were not always notified as required. In the case of a resident with no cognitive impairment but significant physical care needs, there was a lack of documentation regarding behavioral incidents and refusals of care. Staff described episodes where the resident refused to use a mechanical lift for transfers, became combative, and refused assistance with toileting and hygiene. Despite these events, there were no corresponding progress notes or behavior documentation in the resident's record for the relevant period. The care plan also did not reflect the use of the mechanical lift until months after the resident began requiring it, and staff acknowledged that these behaviors and refusals should have been documented according to facility policy. Another resident's record lacked documentation of failed attempts to arrange telehealth appointments with a specialist. The resident reported being informed by the facility that the specialist discontinued services due to missed appointments and that the clinic was uncooperative in setting up telehealth visits. Management confirmed that communication with the clinic occurred but admitted that documentation of these efforts was not completed. These omissions in recordkeeping are contrary to accepted professional standards and the facility's own policies.
Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policies when concerns about the treatment of a resident were not reported within the required two-hour timeframe, and a thorough investigation was not completed. A staff LPN observed two CNAs neglecting call lights, delaying rounds, and interacting with a resident in a condescending and dismissive manner during the night shift. The resident, who had a BIMS score indicating no cognitive impairment and required assistance for toileting, was denied timely help and subjected to inappropriate communication by staff. The LPN reported these concerns to a day shift RN but was unsure if further reporting occurred, and only provided a written statement to the DON after a delay of more than two days. The facility's investigative file revealed significant gaps in the investigation process. Although the facility's policy required immediate reporting of abuse allegations to the administrator and a thorough investigation, the initial report to the state agency was not made until several days after the incident. The investigation did not include follow-up interviews with the resident after her initial statement, nor did it include interviews with her roommate regarding the incident or with all staff who had contact with the resident during the relevant period. The social worker who interviewed the resident did not pursue further questions or follow-up, and the DON was unaware of key statements made by the resident. Documentation of the investigation was incomplete, lacking evidence of follow-up on the resident's psychosocial status and missing interviews with relevant staff and witnesses. The facility's own policies outlined the need for comprehensive documentation and interviews, but these steps were not fully carried out. The resident involved reported being left on the side of her bed for two hours in pain and feeling abused, but there was no documented follow-up to assess her well-being after the incident.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report concerns regarding the treatment of a resident within the required two-hour timeframe after the alleged incident was observed. According to the records, a resident with a BIMS score indicating no cognitive impairment, who required substantial assistance for toileting and was frequently incontinent, was involved in an incident where two CNAs were observed neglecting call lights, delaying rounds, and interacting with residents in a condescending and dismissive manner. The CNAs were also reported to have refused to assist the resident to the bathroom without the use of a mechanical lift, despite the resident's insistence that she did not need it, and ultimately denied her request to use the bathroom. The LPN who witnessed these events reported that the CNAs left call lights unanswered for extended periods, failed to perform regular rounds, and did not provide basic care such as turning hospice residents or passing out ice water. The LPN observed the CNAs speaking to residents in a manner she found inappropriate and witnessed them laughing at and dismissing the resident's needs. The LPN did not immediately report these concerns to facility management or the appropriate authorities, instead waiting until after her next shift to provide a written statement to the DON. The facility's policy required that any suspicion of abuse, neglect, or exploitation be reported immediately, defined as within two hours, to the administrator and other officials as required by law. However, the initial report to the State Agency was not made until several days after the incident, and the LPN acknowledged uncertainty about the reporting process and who to contact at the time. The delay in reporting was confirmed by both the LPN and the DON, who stated that the LPN was educated on the need for immediate reporting after the fact.
Failure to Conduct Thorough Investigation of Alleged Resident Mistreatment
Penalty
Summary
The facility failed to conduct a thorough investigation into allegations of staff misconduct and potential resident mistreatment. Documentation revealed that a resident, who had no cognitive impairment and required substantial assistance for toileting, reported being left on the side of her bed for two hours after being told by an aide that she would not be helped. The resident described experiencing pain as a result. Staff statements indicated that call lights were ignored for extended periods, rounds were delayed, and staff interactions with residents were at times rude and dismissive. An LPN observed aides refusing to assist residents promptly and speaking to them in a condescending manner, including an incident where a resident was denied bathroom assistance unless she agreed to use a mechanical lift, which she refused. The facility's investigative file included statements from some staff and a resident questionnaire, but lacked critical follow-up. There was no documented follow-up interview with the resident who made the abuse allegation to assess her psychosocial status after the incident. The investigative file also did not include an interview with the resident's roommate regarding the specific morning in question, nor were staff from all shifts who had contact with the resident after the alleged incident interviewed. Additionally, a key RN who was reportedly informed of the concerns was not interviewed, and attempts to contact her were unsuccessful. The facility's policy required thorough investigation of all allegations, including interviews with witnesses, the resident, staff from all shifts, and the resident's roommate, as well as complete documentation. The investigation did not meet these requirements, as several necessary interviews and follow-ups were omitted, and there was a lack of documentation regarding checks on the resident's well-being after the incident.
Failure to Update Care Plan After Change in Transfer Assistance
Penalty
Summary
The facility failed to update the care plan for one resident after her transfer assistance needs changed to require the use of a mechanical lift (EZ stand). The resident, who had no cognitive impairment and was dependent on staff for toileting and transfers, experienced a decline in mobility and began requiring mechanical lift assistance. Despite this change, her care plan and bedside Kardex continued to document the need for substantial assistance of two staff for transfers, without specifying the use of the EZ stand. Staff interviews revealed that the change in transfer method was communicated verbally between shifts rather than through formal care plan updates. Multiple staff members, including CNAs and the LPN, confirmed that the resident's transfer method had changed and that the care plan was not updated to reflect this. The DON acknowledged that care plans should be updated as needed and that staff rely on the Kardex and EHR for resident care information. The facility's policy required comprehensive, person-centered care plans to be developed and implemented for each resident, but this was not followed in this instance, resulting in the care plan lacking documentation of the mechanical lift requirement.
Failure to Implement Individualized Interventions for Resident with Dementia-Related Behaviors
Penalty
Summary
The facility failed to implement additional individualized interventions for a resident with moderate cognitive impairment and dementia who exhibited behavioral issues during toileting assistance. The resident, who required substantial assistance for transfers and toileting and was frequently incontinent, refused staff help to use the bathroom and to be checked or changed when incontinent. Staff interactions revealed that the resident became upset and combative when told she needed to use a mechanical lift, refusing both the equipment and staff assistance, and using verbal aggression toward staff members. Staff interviews indicated that after the resident refused care, the CNAs and the LPN did not attempt further individualized approaches or interventions beyond documenting the refusal. The LPN declined to assist further, stating that nothing more could be done if the resident refused, and the CNAs continued to check on the resident but were unable to provide care due to her continued refusals. The staff did not attempt to involve other potential interventions, such as involving the nurse in a different approach or contacting the resident's family, despite the facility's policy on problematic behavior management and the DON's later statements about possible alternative strategies. The care plan for the resident included directions for staff to use calm communication and not to argue, but there was no evidence that additional or individualized non-pharmacological interventions were attempted when the resident refused care. The facility's policy required staff to identify and manage problematic behaviors with appropriate interventions, but in this instance, staff actions were limited to initial attempts and documentation, without further escalation or adaptation to the resident's behavioral needs.
Expired Medications and Supplies Found in Medication Storage Areas
Penalty
Summary
Surveyors observed that medications and supplies in the medication room and on medication carts were not consistently stored within their expiration dates. During a medication room inspection with an LPN present, 12 unopened bottles of Aspirin 81 mg were found to be expired. The LPN stated she believed the DON had overlooked these items. Additionally, a check of two medication carts with a CMA present revealed an expired, empty syringe and an opened bottle of expired Aspirin 81 mg filled to the rim. The CMA was informed of the expired items at the time of the observation. Staff interviews indicated a lack of consistent oversight regarding expired items. One LPN denied having issues with expired items, stating that if expired items are found, they are usually treatment supplies that are rarely used and are discarded when noticed. The DON reported that she attempts to review the medication room and that the pharmacy conducts monthly checks, with staff also reviewing medications and supplies as they are put away. The facility's policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner.
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. Resident #15, who has quadriplegia and is dependent on staff for various activities, reported that call lights often took longer than 20 minutes to be answered, with delays extending up to an hour during overnight shifts. Observations confirmed that call lights in Resident #15's room were not answered promptly. Similarly, Resident #20, diagnosed with Multiple Sclerosis, experienced delays of up to 30 minutes or more for call light responses, as corroborated by staff interviews indicating that insufficient staffing contributed to these delays. Resident #37, who requires assistance with transfers, reported long wait times for call light responses, affecting her ability to accommodate family visits. Resident #21, who is totally dependent on staff for transfers, recounted an incident where he waited over an hour on a bedpan for assistance. The Director of Nursing acknowledged the facility's expectation for call lights to be answered within 15 minutes but admitted there was no formal policy in place. These findings highlight the facility's failure to meet the needs of residents due to inadequate staffing levels, as evidenced by the delayed response to call lights.
Inaccurate Assessment of Anticoagulant Use
Penalty
Summary
The facility failed to accurately assess the use of an anticoagulant for a resident during the observation period of the Minimum Data Set (MDS). The MDS for the resident documented the use of an anticoagulant, but upon review, it was found that the resident was only taking baby Aspirin, which is an anti-platelet, not an anticoagulant. The resident confirmed that the only blood thinner they took was baby Aspirin. The Medication Administration Record (MAR) showed a physician's order for Aspirin 81 mg daily for pain. The MDS coordinator identified Aspirin as an anticoagulant due to the resident's history of blood clots. However, the Regional Clinical Reimbursement Specialist clarified that Aspirin should be coded as an anti-platelet according to RAI guidelines, indicating the MDS was incorrectly coded. The facility's policy requires the MDS Coordinator to ensure accurate resident assessments, which was not adhered to in this case.
Infection Control Lapse in Medication Administration
Penalty
Summary
The facility failed to adhere to appropriate infection prevention practices during medication administration for a resident with an enteral tube. The resident, who had a BIMS score indicating no cognitive impairment and a diagnosis of quadriplegia, was observed receiving medication through an enteral tube by a registered nurse. Although the nurse completed hand hygiene and wore gloves, they did not don a gown as required by the facility's policy for enhanced barrier precautions for residents with indwelling medical devices such as feeding tubes. The facility's policy, aligned with CDC guidelines, mandates the use of personal protective equipment, including gowns, during high-contact care activities for residents with indwelling medical devices, regardless of their MDRO colonization status. The Director of Nursing confirmed that the expectation was for staff to wear appropriate PPE, including gowns, during such procedures. The failure to follow these precautions was acknowledged by the Director of Nursing, highlighting a lapse in adherence to infection control protocols.
Inadequate Bathing and Hygiene Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide adequate bathing and personal hygiene care for several residents, as observed through clinical record reviews, interviews, and facility policy reviews. Resident #5, who required assistance from two staff members for bathing, did not receive a bath on one scheduled day, and reported receiving only one bath per week due to staff shortages. Resident #8, who required total assistance for bathing, was found to have long fingernails and reported not having a bath for a month, with no staff offering or explaining the lack of bathing services. Resident #9, who required assistance from two staff members for bathing, went ten days without a bath, despite being scheduled for three baths a week. His son confirmed the inconsistency in bathing schedules and noted that staff often cited understaffing as the reason for missed baths. Resident #11, who required partial assistance with personal hygiene, was observed with long leg hair and stated that staff did not assist with shaving, although she desired it. Staff interviews revealed that baths were not consistently completed due to insufficient staffing, with some staff stating that baths were not done on evening shifts unless there was enough staff. The Director of Nursing confirmed that residents should receive baths twice a week unless they refuse, and that nail trimming should occur during bath times. The facility's policies emphasized the importance of maintaining residents' personal hygiene and dignity, which were not upheld in these instances.
Staffing Shortages Lead to Delayed Call Light Responses
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, particularly in answering call lights in a timely manner. Observations on a specific date revealed numerous call lights going unanswered for extended periods, ranging from 16 to 40 minutes. This issue was corroborated by resident council meeting notes and grievance forms, where residents consistently reported delays in call light responses. For instance, Resident #9 expressed frustration over the time it took to get assistance, and Resident #6 reported waiting 45 minutes in soiled conditions before receiving help. Interviews with staff and residents further highlighted the staffing inadequacies. Staff members, including CNAs, reported that call lights could take over 30 minutes to be answered due to insufficient staffing levels. They described scenarios where only two CNAs were available to assist a significant number of residents, many of whom required two-person assistance for transfers. This staffing shortage was particularly acute during evening and weekend shifts, leading to delays in attending to residents' needs and completing routine tasks. The facility's Director of Nursing (DON) acknowledged that staffing was based on census rather than resident acuity, which contributed to the problem. Despite the expectation that call lights be answered within 15 minutes, this standard was not consistently met. The DON admitted that while efforts were made to increase staffing, call-ins and other issues often left the facility understaffed, impacting the quality of care provided to residents.
Inadequate Kitchen Staffing Leads to Unqualified Staff Performing Dietary Tasks
Penalty
Summary
The facility failed to ensure that qualified staff were consistently available to assist in the kitchen, leading to untrained staff from other departments stepping in to perform dietary tasks. This issue was highlighted by grievances from residents who expressed dissatisfaction with meal services, such as not receiving ordered meals and being asked to prepare their own food. The facility's census was reported to be 30 residents, and the dietary manager's unexpected absence exacerbated the staffing shortage, prompting the administrator to pull staff from other departments to fill in. Multiple staff members, including CNAs, nurses, and maintenance personnel, reported being asked to assist in the kitchen without proper training or certification. Some staff members, like Staff E CNA, were involved in cooking meals despite lacking dietary certifications, relying instead on previous experience and kitchen charts to guide them. Others, like Staff P LPN, assisted with meal service under the supervision of the dietary manager, who was unable to perform her duties due to medical reasons. The facility's job descriptions for CNAs and cooks did not include kitchen duties for CNAs, indicating a misalignment between staff roles and responsibilities. Despite the lack of formal training, staff were frequently asked to perform dietary tasks, such as serving meals and preparing room trays, due to the facility's inability to maintain adequate kitchen staffing. This situation persisted over several months, with staff expressing concerns about their lack of training and the facility's reliance on unqualified personnel to meet dietary needs.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to store and serve food in a sanitary manner, as observed during a survey. On two separate occasions, hamburger meat was found in a gray hard plastic bin with red, bloody fluid at the bottom, indicating improper storage. Additionally, moldy green peppers were found in the walk-in cooler, suggesting a lack of proper food inspection and disposal. These observations were made despite the facility's policy requiring food to be stored in a manner that complies with safe food handling practices. In the dish area, a dietary aide was observed using the same pair of gloves to handle both dirty and clean dishes, violating infection control practices. The aide moved a trash can, handled clean dishes, and cleaned the dirty side of the dish area without changing gloves or washing hands between tasks. This practice was contrary to the facility's policy, which requires handwashing between tasks to prevent cross-contamination. Furthermore, a staff member was seen handling ready-to-eat food with bare hands, contrary to the facility's policy that prohibits direct contact with food without gloves. The staff member plated sandwiches and handled various items without wearing gloves, even after touching her hairline and clothing. This behavior was inconsistent with the facility's guidelines, which mandate the use of gloves or utensils when serving ready-to-eat foods.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by the behavior of Staff P, an LPN, towards multiple residents. Resident #5, with no cognitive impairment, reported that Staff P was dismissive and unhelpful, refusing to assist her roommate and declining to turn off the overhead light when requested. Resident #6, also cognitively intact, overheard Staff P using profane language and speaking negatively about residents while at the nurse's station. Resident #8, who communicates using a board, indicated that Staff P was not nice when speaking with him. These interactions suggest a pattern of disrespectful communication by Staff P, impacting the residents' sense of dignity. Interviews with other staff members corroborated the residents' accounts, with several CNAs and LPNs acknowledging Staff P's use of inappropriate language and negative comments about residents. Staff I and Staff E reported that Staff P frequently used profanity and complained about residents, while Staff H noted that Resident #5 refused treatment from Staff P due to her demeanor. The Director of Nursing was informed of these issues and acknowledged the need to address the negative environment created by Staff P's behavior. The facility's policies on resident rights and dignity emphasize the importance of treating residents with kindness and respect, which was not upheld in these instances.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident, leading to an elopement incident. The resident, who had a BIMS score indicating mild cognitive impairment and was identified as an elopement risk, left the building without staff knowledge. On the day of the incident, staff responded to an alarmed door but did not physically check outside to confirm if a resident had exited. The staff member assumed they saw another staff member and did not initiate a head count to ensure all residents were accounted for. The resident was later found by an Assisted Living (AL) attendant and returned to the facility without injuries. The facility's investigation revealed that the staff member who responded to the alarm did not follow proper procedures, such as going outside to check for residents or conducting a head count. The facility's policy and procedures for responding to door alarms were not effectively followed, contributing to the resident's unsupervised exit. Interviews with staff indicated a lack of consistent understanding and execution of the facility's elopement protocols. Some staff members were unaware of the need to conduct a head count or physically check outside when an alarm sounded. The facility's documentation and training on elopement prevention and response were insufficient, as evidenced by the staff's varied responses and the absence of a clear protocol for handling such incidents.
Improper Disposal of Room Trays
Penalty
Summary
The facility failed to properly dispose of room trays with leftover food in a timely manner, as observed during a survey. On multiple occasions, trays with leftover food and drinks were found in residents' rooms long after meals were served. For instance, a dietary aide reported finding dishes in residents' rooms after returning from a weekend off, indicating that trays were not collected promptly. Additionally, a resident reported that her dishes from breakfast and lunch were not picked up until after she had gone to the dining room for dinner. Another resident's room was observed with a plate, silverware, and a coffee mug left on the bedside table for an extended period. The Director of Nursing acknowledged that the responsibility for collecting room trays is shared between dietary and nursing staff, but noted that there is some ambiguity in the facility's policy regarding the timing of tray collection. The policy states that trays should be collected within an hour of meal completion, but the Director mentioned that it is often left to the discretion of the resident. The facility's meal times are set, but the lack of adherence to the policy resulted in trays being left in rooms for prolonged periods, contributing to the deficiency.
Improper Storage and Use of Vape Pens
Penalty
Summary
The facility failed to ensure proper storage and use of vape pens for two residents. Resident #6 had three vape pens observed in his room without any documentation in his clinical record regarding his ability to smoke with or without supervision. Additionally, Resident #6 was seen outside with staff assistance using his vape pen. Resident #7 also had no documentation in her clinical record about her ability to smoke with or without supervision. Staff were aware that Resident #7 used her vape pen in her room, which contained THC and CBD, and she claimed it was prescribed for pain management. Despite the facility's policy requiring smoking evaluations and designated smoking areas, Resident #7 used her vape pen indoors. The facility's smoking policy, revised in 2017, mandates that residents be informed of designated smoking areas and evaluated for their ability to smoke safely. The policy prohibits smoking inside the facility and requires that residents with smoking privileges not keep smoking articles in their possession. However, Resident #7 was found with a vape pen and THC gummies in her room, which were later removed by management after a police officer's visit. The Director of Nursing confirmed that Resident #7 had not been going outside to smoke as required by the policy, and the resident was educated about the prohibition of such items in the facility.
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A resident with severe cognitive impairment, multiple comorbidities (including Parkinson’s disease and CVA), high fall risk, and frequent incontinence experienced numerous unwitnessed falls over several months despite documented needs for substantial/maximal assistance and supervision. The care plan and facility policy called for individualized fall interventions and visual supervision, yet the resident repeatedly self-transferred in the room, common areas, and between the dining room and therapy gym, often being found on the floor after staff heard yelling or noticed the resident missing. Staff interviews confirmed that the resident was typically placed near the nurses’ station or in common areas for increased or visual supervision, but staff were not consistently present or able to intervene before the resident attempted unsafe transfers or tried to assist other residents, leading to repeated injuries such as abrasions and skin tears.
Two residents with cognitive impairment were not adequately protected from sexual abuse by another resident. One resident reported that a male resident in a wheelchair entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket until she screamed and used her call light, after which he left. Shortly afterward, staff found the same male resident in bed with another resident, whose pants and brief were partially down, with his hand inside her pants on her buttocks; she was half asleep and unable to describe what happened. Staff interviews indicated delays and hesitancy in documenting and reporting the incidents to law enforcement and families, with nursing staff stating they were initially told by the DON not to document or report because penetration was not observed or the events were not physically witnessed. The affected resident later became more withdrawn and uncomfortable in common areas when the alleged perpetrator was present, while the facility’s own abuse policy defined sexual abuse as non-consensual sexual contact of any type and guaranteed residents’ right to be free from abuse.
A resident with moderate cognitive impairment, multiple chronic conditions, and chronic pain ordered Oxycodone HCl 15 mg every six hours received incorrect doses after the pharmacy changed the tablet strength from 5 mg to 15 mg. Staff had previously administered three 5 mg tablets to equal the ordered 15 mg, but when new 15 mg tablets arrived, a CMA first gave a total of 25 mg by combining remaining 5 mg tablets with a 15 mg tablet, then an LPN and the same CMA each later administered three 15 mg tablets (45 mg) while documenting the doses as if they matched the order. Progress notes described the resident as pale, confused, with garbled speech, hallucination-like behavior, pinpoint pupils, and intermittent drowsiness. Interviews showed staff did not re-check the tablet strength or compare the new medication card to the MAR and reported there was no formal process to alert staff to dose changes with new medication cards.
The facility failed to maintain a clean, comfortable, homelike environment when multiple residents’ beds remained stripped or unmade well into the morning and one room was observed with dried fluid on the floor and debris along the baseboard heater and wall. A cognitively intact resident reported wanting the bed made by the end of breakfast, but surveyors twice observed linens rolled at the foot of the bed with the bed unmade. Another resident with moderate cognitive impairment and physical care needs was found lying in bed with only a small lap blanket while all bedding was bunched at the bottom of the bed, and the resident stated staff had not returned to make the bed. CNAs and an LPN described busy workloads, stripped beds, and delays in bed-making, while leadership acknowledged expectations that beds be made by mid-morning and that rooms be clean, consistent with the facility’s homelike environment policy.
The facility failed to maintain kitchen sanitation and follow food safety practices, as shown by incomplete monthly cleaning checklists, unlabeled and undated food items, improper storage of raw meat above ready-to-eat foods, and dried food and debris on floors and equipment. During meal service, dessert plates were transported uncovered on hallway carts, random rags were left on the kitchen floor, and dietary staff used gloves improperly, touched non-food surfaces, wiped their nose, drank from a personal mug, and resumed food service without proper hand hygiene. Another staff member briefly rinsed hands after handling dirty dishes and then passed resident trays without appropriate handwashing, contrary to the facility’s own food safety and employee hygiene policies.
A resident-to-resident altercation occurred, and although the residents were immediately separated, the event was not reported to the state survey agency within the required timeframe. The incident was documented as having occurred weeks before it was recognized and reported as an allegation of abuse. Interviews with the Systems Process and Policy Specialist and the Administrator confirmed that the event met criteria for abuse reporting and should have been reported within 24 hours without serious injury or within 2 hours with serious injury, consistent with the facility’s abuse reporting policy and state requirements. Former administration did not complete this required timely reporting.
The facility failed to maintain comprehensive, person-centered care plans for three residents with significant clinical needs. One resident was on ongoing Duloxetine therapy, another was receiving Trazodone and Apixaban with diagnoses of Alzheimer’s disease, depression, and bipolar disorder, and a third had Parkinson’s disease, benign prostatic hyperplasia, and a newly placed Foley catheter for urinary retention. Despite MDS assessments and active physician orders for antidepressants, anticoagulants, and catheter care (including output monitoring, leg bag use when out of bed, and routine catheter changes), the residents’ care plans lacked corresponding problems, goals, and measurable interventions. The DON and Administrator acknowledged that dementia, anticoagulant use, Alzheimer’s disease, antidepressant use, and catheter use had not been incorporated into the individualized care plans as required by facility policy.
A resident with morbid obesity, heart failure, and intact cognition reported daily use of a female urinal that surveyors observed to be soiled with feces on the outside and urine scale in the bottom, with a bent top that the resident said reduced its effectiveness. The resident stated the urinal had not been changed for about three months and was not cleaned weekly. The facility lacked a urinal care policy, and the DON reported not knowing how staff managed this resident’s urinal, while noting that male urinals are changed monthly and expressing uncertainty about the availability of a replacement urinal.
A resident with moderate cognitive impairment was sent to the ED via ambulance for evaluation and oxygen after an on-call provider’s order, but the resident’s daughter, listed as emergency contact and POA, was not notified at the time of transfer. The LPN who arranged the transfer informed only the resident, considering him his own POA, and did not contact the daughter, later acknowledging this omission. A subsequent LPN learned from ED staff that the resident had been transferred to another hospital for urosepsis and kidney failure and then called the daughter, who reported she first learned of the situation only after the resident had been life flighted and was already at the second hospital. The DON confirmed the daughter should have been notified of the emergency transfer in accordance with the facility’s change-of-condition reporting policy, which requires notifying and documenting contact with the family/responsible party.
Staff were informed that a male resident had entered one resident’s room and attempted to get into bed with her, and shortly thereafter found him in bed with another resident whose pants and brief were partially down while his hand was on her buttocks. One resident was cognitively intact with CAD and diabetes, and the other had severe cognitive impairment and required assistance with personal care. Although facility policy required immediate reporting of abuse allegations to the Administrator and state agencies, the Administrator and DON were not fully informed at the time of the incidents, and the allegation was not reported to state authorities within the required 2-hour timeframe.
Failure to Provide Effective Supervision and Fall-Prevention for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and effective fall-prevention interventions for a resident with severe cognitive impairment and a significant fall history. The resident had a BIMS score of 2, indicating severely impaired cognition, was oriented to self only, and exhibited dementia progression, short recall, impulsiveness, and frequent self-transfers. The MDS documented substantial/maximal assistance needs for bed mobility and transfers, supervision for toileting and transfers, and frequent urinary incontinence. Diagnoses included Parkinson’s disease, cerebrovascular accident, diabetes mellitus, and renal insufficiency, all contributing to a high fall risk. The facility’s own fall management policy required individualized care plans, IDT review of fall patterns, and interventions based on causal factors, but the resident experienced thirteen falls over approximately three months. Incident reports show repeated unwitnessed falls in both the resident’s room and common areas despite the resident being identified as high risk for falls and placed near the nurses’ station or in common areas for “increased” or “visual” supervision. On one occasion, staff heard yelling and found the resident picking himself up from the bathroom floor after self-transferring to the toilet without a walker or assistance and without using the call light. Another incident in a common area involved the resident being found on the floor with abrasions after staff only heard yelling and then discovered him lying on his side. In another fall, the resident attempted to assist another resident in the common area, stood up from a recliner, lost balance, and sustained a skin tear, indicating that staff were not sufficiently monitoring his movements or preventing unsafe attempts to help others. Additional falls occurred while the resident was supposed to be under observation near the nurses’ station or in the dining/common areas. In one event, an LPN sitting at the nurses’ station on the phone turned her head and saw the resident in mid-fall out of his recliner, demonstrating that the resident was able to initiate transfers and fall without timely staff intervention despite the expectation of visual supervision. In another event, the resident was last known to be seated in his wheelchair at a dining room table, but when the nurse returned from another resident’s room, the resident was missing and was later found on his knees in the therapy gym, which was connected to the dining room by several short hallways. Interviews with LPNs and the DON confirmed that the expectation was for visual supervision and that the resident was frequently placed in the living room/common area or near the nurses’ station, but staff could not account for where other staff were at the time of some falls. The pattern of repeated unwitnessed falls, self-transfers, and inadequate monitoring despite known high fall risk and cognitive impairment demonstrates the facility’s failure to implement and maintain effective, consistent supervision and fall-prevention interventions as required by its fall management policy and the resident’s care plan.
Failure to Protect Residents From Sexual Abuse and to Report and Document Incidents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse and to implement appropriate protective interventions after serious allegations involving one male resident and two female residents. Resident #3, who had a history of muscle weakness, stroke, diabetes mellitus, and a BIMS score of 12 indicating moderate cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair (Resident #2) entered her room, moved her bedside table, touched her leg, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light and screamed twice, after which he left the room. Resident #3 later described ongoing distress when seeing Resident #2 in common areas, reported difficulty sleeping when she saw him, and expressed that she had told others she would kill him if he touched her again. She also stated that it bothered her that he had violated another person and that she did not understand why he was allowed to sit at a table with residents who could not defend themselves. The same day, Resident #50, who had diagnoses including need for assistance with personal care, hypertension, and unspecified cognitive symptoms with a BIMS score of 6 indicating severe cognitive impairment, was found in a more advanced incident with Resident #2. According to the incident report and progress notes, staff discovered Resident #2 in bed with Resident #50, with her pants and brief halfway down and his left hand inside her pants on her buttocks. Her wheelchair was parked in front of the bed and the door was locked. Resident #50 was lying on her side, half asleep, and was unable to state or describe what had happened. Both residents were separated, and Resident #2 was later placed under 1:1 monitoring at the nursing station, but the documentation shows that the discovery of this incident occurred only after staff had been alerted that Resident #2 had already attempted to get into bed with Resident #3. Multiple staff and family interviews revealed failures in timely reporting, documentation, and implementation of protective interventions consistent with the facility’s abuse-prevention policy. Resident #3’s daughter stated her mother called her about the incident in the afternoon, but the facility did not notify her until several hours later, and that police were not called until the evening. Staff I, the RN on duty, reported that the DON told her that because there was no vaginal penetration, she should call the police later and that the police would probably only take a report over the phone. Staff N, an LPN, stated she was told that Staff I had initially been instructed not to document the incident because they did not know exactly what Resident #2 was doing, and that she insisted the incident needed to be reported. Staff J, an LPN, similarly stated that the DON told Staff I not to make a note of the incident because it was not physically witnessed, despite Staff I stating she had witnessed it. Staff interviews also documented that Resident #3 became more self-isolating and uncomfortable participating in activities or remaining in the dining room when Resident #2 was present, while Resident #2 remained in the facility. The facility’s written policy defined abuse, including sexual abuse as non-consensual sexual contact of any type with a resident, and stated that each resident has the right to be free from abuse, neglect, misappropriation, and exploitation, but the actions and inactions described did not align with these stated protections for Residents #3 and #50.
Significant Oxycodone Dosing Error Due to Failure to Verify Tablet Strength and Orders
Penalty
Summary
The deficiency involves the facility’s failure to prevent a significant medication error for a resident receiving opioid therapy for chronic pain. The resident had moderate cognitive impairment and multiple diagnoses including anxiety, COPD, depression, heart failure, and respiratory failure, and was care planned for chronic pain with interventions to monitor for opiate side effects. The physician’s order, in place since early March, specified Oxycodone HCl 15 mg every six hours. Initially, the pharmacy dispensed 5 mg tablets with instructions on the medication card and controlled drug record to administer three tablets every six hours to equal the ordered 15 mg dose, and staff followed this regimen. On a later date, the pharmacy delivered a new supply of Oxycodone HCl as 15 mg tablets, with the new controlled drug record and medication card directing staff to administer one tablet every six hours. However, on the afternoon when the new card arrived, a CMA completed the remaining 5 mg tablets from the old card (two tablets) and then took one 15 mg tablet from the new card, resulting in a 25 mg dose instead of the ordered 15 mg. The following morning, an LPN documented administering three 15 mg tablets (45 mg total) and signed the controlled drug record and MAR as if the ordered dose had been given. Later that same day at midday, the CMA again documented administering three 15 mg tablets (another 45 mg total) and signed the MAR as if the ordered dose had been provided. Progress notes later that day documented the resident appearing pale, with garbled speech, confusion, and pinpoint pupils, and then later reaching out to grab at the air, laughing about it, with pupils measured at 1 mm and intermittent drowsiness, though easily arousable. An RN associated with the resident’s primary care provider assessed the resident that afternoon and found the resident drowsy but responsive, with a contracted arm, shakiness, and pinpoint pupils, and reported that the primary care provider considered possible opioid overdose among other differential diagnoses. Facility staff interviews revealed that the CMA and LPN continued to give three tablets because that had been the prior practice with the 5 mg tablets, did not verify the tablet strength or compare the new medication card to the MAR, and that there was no formal process in place to notify staff of dose changes when new medication cards with different tablet strengths were received.
Unmade Beds and Poor Room Cleanliness Undermine Homelike Environment
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not making beds in a timely manner and not maintaining room cleanliness for several residents. For one cognitively intact resident (BIMS 14), surveyors observed on multiple occasions the bed linens rolled up at the foot of the bed and the bed unmade well into the morning, despite the resident’s stated preference that the bed be made by the end of breakfast and certainly before lunch. Another resident with moderate cognitive impairment (BIMS 9) and diagnoses including unspecified intellectual disabilities, muscle weakness, and need for assistance with personal care was observed lying in bed with only a small lap blanket while all bedding was wrapped at the bottom of the bed; the resident reported that a staff member had placed the bedding there earlier that morning and had not returned to make the bed. Additional observations on the same hall showed other beds without bedding at all. Staff interviews revealed that CNAs typically make beds when residents are gotten up in the morning, but one CNA reported it was his first day working at the facility, that the morning was very busy, and that he was unable to get beds made before being pulled away from the hall. Another CNA who started at 10:00 a.m. stated that when he arrived, beds on the hall had been stripped, linens not changed, and beds not made, and that he could not make the beds until after completing resident care. An LPN reported noticing frequently that resident beds were not made until after 11:00 a.m. and sometimes instructing staff or making beds herself. The DON and Administrator both stated they expected beds to be made by mid-morning and acknowledged that the day in question was not scheduled for housekeeping to strip and remake beds on that hall. In a separate room, surveyors observed a bed pulled away from the wall, streaks of dried fluid on the floor, brown debris along the baseboard heater and on the wall above it, and a white object in the baseboard; the resident confirmed these areas had been present for some time. The facility’s homelike environment policy stated that rooms should be homelike and, per the Administrator, rooms should be clean.
Failure to Maintain Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation and food safety practices as required by its food safety policy. Monthly cleaning checklists posted on the reach-in cooler door for AM/PM aides and cooks showed that most daily cleaning assignments had only been completed once during the month, with several tasks not initialed at all, indicating they were not done. During a kitchen tour, surveyors observed multiple sanitation and storage issues, including unlabeled drink pitchers, dried liquid and food debris on the bottom of the reach-in cooler, and raw ground hamburger stored above ready-to-eat cold cuts with incomplete labels lacking open dates. Additional unlabeled or undated food items included a plastic bag of what appeared to be hard-boiled eggs, a covered green resident bowl, a small plastic storage container, a container labeled cream of chicken soup dated 3/12/26, a container of what appeared to be pickles, and multiple cereal containers without identifying information, including one covered with torn plastic wrap. The kitchen floor had dried liquid and food debris unrelated to the current day's menu, and debris such as dried food splatter, plastic lids, condiment packets, a used rag, wrappers, dust, and food buildup was noted under and around equipment including the dish machine, prep tables, ice machine, and steam tables, as well as dried food splatter on the Kitchen Aid mixer, Robot Coupe, and an outlet box and utility pole. During meal service observations, surveyors noted additional failures to follow food safety and hygiene practices. Two carts with resident room trays left the kitchen with uncovered dessert plates while being transported down hallways. Random white rags were observed on the floor under the ice machine, handwashing sink, reach-in cooler, and the back side of the oven. A dietary aide (Staff I) donned gloves and then touched service cart handles, wiped gloved hands on their clothing, adjusted eyeglasses, and proceeded to portion brownies with the same gloves. Later, the same staff member removed gloves, wiped their nose, drank from a personal mug, then put on new gloves and resumed service without any hand hygiene. Another staff member (Staff J) placed dirty dishes in the dish machine, briefly rinsed hands under water at the handwashing sink, and then resumed passing resident trays without performing proper hand hygiene. In an interview, the Dietary Director and Registered Dietitian acknowledged the poor cleanliness of the kitchen and the improper glove use and inadequate hand hygiene, despite the facility’s written policy requiring proper food storage, covering food during transport, handwashing before distributing trays and between resident contact, and appropriate cleaning of equipment and use of gloves or utensils to avoid bare-hand contact with food.
Failure to Timely Report Resident-to-Resident Altercation as Alleged Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident-to-resident altercation to the state survey agency (SSA) in accordance with federal, state, and facility policy requirements. A facility investigation titled "Resident to Resident Altercation" documented that an incident occurred between two residents on 02/07/2026 at approximately 5:00 PM, during which the residents were immediately separated. The investigation record further documented that the incident was not reported until 03/09/2026, indicating a significant delay between the occurrence of the event and the reporting of the allegation. During an interview on 03/24/2026, the Systems Process and Policy Specialist stated she assumed responsibilities from the previous administrator in early March and, on 03/10/2026, identified that the resident-to-resident interaction had not been reported to the SSA as required. She then reported the allegation of abuse to the SSA on 03/10/2026 and confirmed it should have been reported within 24 hours. In a separate interview on the same date, the Administrator agreed that allegations meeting the criteria for abuse must be reported within 24 hours if there is no injury and within 2 hours if there is injury. Review of the facility’s Abuse Prevention, Identification, Investigation and Reporting Policy, last revised 12/2025, showed that all allegations of neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation must be reported to the Iowa Department of Inspections and Appeals within 2 hours if serious bodily injury occurred, or within 24 hours if serious bodily injury did not occur. Former administration failed to notify the SSA within these required time frames for this incident.
Failure to Update Comprehensive Care Plans for Psychotropic, Anticoagulant, and Catheter Management
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with problems, goals, and measurable interventions for multiple residents with identified clinical needs. For one resident admitted from a short-term hospital stay, the MDS showed antidepressant use, and the EHR contained ongoing physician orders for Duloxetine beginning at admission and later revised in dose and formulation. Despite this, the resident’s care plan, last revised in early March, did not include any problem, goal, or intervention related to antidepressant medication usage. Another resident’s MDS documented use of both anticoagulant and antidepressant medications and diagnoses including Alzheimer’s disease, depression, and bipolar disorder. The EHR showed active orders for Trazodone as an antidepressant and Apixaban as an anticoagulant. However, the resident’s care plan, revised in late December, did not contain problems, goals, or interventions addressing antidepressant use, and the DON later acknowledged that dementia, anticoagulant use, and Alzheimer’s disease should also have been included on this resident’s care plan with appropriate goals and interventions. A third resident’s quarterly MDS indicated intact cognition, an indwelling catheter, a primary diagnosis of Parkinson’s disease with dyskinesia and fluctuations, and additional diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms, depression, and cognitive communication deficit. Progress notes documented a new Foley catheter placed for urinary retention due to neurogenic bladder, and subsequent physician orders directed shift catheter output monitoring, use of a leg drainage bag when out of bed, and routine catheter changes every four weeks. The care plan, last revised in late December, had not been updated by the interdisciplinary team after the March quarterly assessment to include a focus or problem, goals, and interventions for catheter use. During interview and observation, the resident reported that Parkinson’s disease was slowing him down and that staff had not changed his catheter to a leg bag; he was observed using a bed bag under his wheelchair seat. The DON and Administrator both confirmed that the care plan had not been revised to address the catheter with measurable goals and individualized interventions, despite facility policy requiring review and revision of comprehensive care plans after each assessment and with new diagnoses, changes in condition, or new devices.
Failure to Provide Clean, Functional Urinal Supplies for a Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate a resident’s needs and preferences for urinary independence by not providing proper urinal supplies and care. The resident, who had morbid obesity, heart failure, and a BIMS score of 15 indicating no cognitive impairment, reported using a female urinal daily. On observation, the urinal had brown areas on the outside, which the resident identified as feces that had been present for some time, and a urine scale in the bottom. The resident stated the facility had not changed the urinal for approximately three months and did not clean it weekly, and the urinal top was bent, which she said made it work less effectively. The facility did not have a policy on urinal care, and the DON stated she did not know what staff did with this resident’s urinal, acknowledged that male urinals are changed monthly and that this resident’s should be as well, and was unsure if there were any new urinals available for the resident.
Failure to Notify Resident’s POA of Emergency Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition that resulted in transfer to the emergency department. The resident had a BIMS score of 9, indicating moderate cognitive impairment, and was documented as his own POA, with his daughter listed in the EHR profile as emergency contact #1, POA, and care conference person. On the morning of 1/7/26, an on-call provider ordered the resident sent to the ED via ambulance with oxygen, and the LPN (Staff E) documented updating the resident on the orders but did not notify the daughter/POA of the transfer. Staff E later acknowledged she did not notify the daughter at the time of transfer, stating she considered the resident his own POA and that she sent a text to another LPN (Staff D) to let the daughter know the resident had been transferred. Later that morning, Staff D documented speaking with an ED nurse and learning the resident had been transferred to another hospital due to urosepsis and kidney failure, and then documented calling and notifying the resident’s daughter. The daughter/POA reported she was not notified when the resident was first sent to the ED and only learned of the situation after he had been life flighted to a second hospital, stating the nursing home called her about 30 minutes before the second hospital notified her. Staff D confirmed that when she arrived for her shift, the previous nurse (Staff E) had not notified the daughter, and that the daughter was upset. The DON stated the resident was his own POA but confirmed the daughter, listed as emergency contact #1, should have been notified of the emergency transfer and was not. Facility policy on Change of Condition Reporting required licensed nurses to inform the family/responsible party of a change of condition and document all notification attempts, including time and response, which was not followed in this case.
Failure to Timely Report Resident-on-Resident Abuse Allegations to State Authorities
Penalty
Summary
The facility failed to timely report allegations of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours for two residents. Resident #3, who had coronary artery disease, diabetes mellitus, muscle weakness, and a BIMS score of 12 indicating no cognitive impairment, reported that while she was in bed with her door partially closed, a male resident in a wheelchair entered her room, approached her bed, touched her leg, moved her bedside table, and placed his hand under her blanket attempting to touch her. She stated she pushed her call light, screamed twice, and that a neighboring resident also activated a call light. Staff documentation reflected that a caregiver informed the RN at the nurses’ station that Resident #2 had been in Resident #3’s room attempting to get into bed with her, prompting the RN to immediately go down the hall to check on the situation. Resident #50, who had diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, was subsequently found by staff in bed with the same male resident. At approximately 3:22 p.m., the RN and caregivers located Resident #2 in bed with Resident #50, with Resident #50’s pants and brief halfway down and Resident #2’s hand in her pants on her buttocks, and his wheelchair parked in front of her bed with the door locked. Resident #50 was lying on her side, half asleep, and was unable to describe what had occurred. Facility policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate state or federal agencies within applicable timeframes. Interviews with the Administrator and DON revealed that the Administrator did not learn of the incident until later that evening, at which time she reported it to the state, and the DON stated she had been called around 3:00 p.m. but was not informed about the touching or that a resident had been in bed with another resident, resulting in the allegation not being reported to DIAL within the required 2-hour timeframe.
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