Azria Health Longview
Inspection history, citations, penalties and survey trends for this long-term care facility in Missouri Valley, Iowa.
- Location
- 1010 Longview Road, Missouri Valley, Iowa 51555
- CMS Provider Number
- 165373
- Inspections on file
- 28
- Latest survey
- November 25, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Azria Health Longview during CMS and state inspections, most recent first.
A resident, assessed as cognitively intact but with a care plan noting risk for impaired thought processes, gave a CNA money on two occasions after the CNA discussed personal financial and domestic issues. The CNA was observed in the resident's room with the resident's wallet, and the resident later confirmed giving the CNA a total of $112. The CNA denied the transactions, but facility records and interviews supported the resident's account. Facility policy prohibits staff from accepting money from residents, and the CNA had acknowledged this policy.
A facility area contained accident hazards and staff did not provide adequate supervision to prevent accidents, as observed by surveyors during the inspection.
The facility did not complete required self-administration assessments for two residents who were found with medications at their bedside and self-administering them, contrary to facility policy. Additionally, a resident with severe cognitive impairment and a history of falls experienced a fall resulting in a hip fracture, but staff did not consistently assess, document, or communicate changes in pain and bruising, nor did they promptly obtain an x-ray as directed by the physician.
The facility was cited for failing to implement an effective QAPI program, resulting in repeat deficiencies related to pressure ulcer prevention and infection control. The Administrator confirmed that Enhanced Barrier Precautions were not discussed in Quality Assurance meetings, and ongoing challenges with pressure ulcer management persisted, despite facility policy requiring regular review and improvement activities.
Staff failed to consistently use Enhanced Barrier Precautions (EBP) and universal infection control measures for several residents with wounds, indwelling catheters, and multidrug-resistant organisms. Observations showed staff did not always perform hand hygiene between glove changes, did not use gowns as required, and sometimes used improper techniques during wound and peri care, despite facility policies and staff awareness of the requirements.
Multiple residents with complex medical needs experienced significant delays in call light response, with documented wait times often exceeding 15 minutes and sometimes reaching up to 45 minutes. Staff interviews and call light logs confirmed that the facility did not consistently meet its policy of timely response, resulting in residents waiting for essential assistance such as toileting and being put to bed.
Two residents did not receive care according to physician orders, including missed medication administration for a newly admitted resident and inconsistent wound care for another resident with a chronic ulcer. Staff failed to notify the physician of missed medications, delayed pharmacy communication, and did not consistently apply wound dressings or compression stockings as ordered, resulting in increased edema and wound deterioration.
A resident with physical impairments and no cognitive deficits waited over 15 minutes for toileting assistance after activating the call light. Staff acknowledged the request but failed to respond promptly, resulting in the resident experiencing incontinence and feelings of embarrassment and loss of dignity. Staff interviews confirmed the delay exceeded facility expectations for call light response.
A resident with multiple diagnoses, including cancer and diabetes, was receiving daily Furosemide as ordered by a physician, but the care plan did not document the use of this high-risk medication. The DON confirmed that diuretic use should have been included in the care plan, and facility policy requires care plans to be updated as resident conditions change.
A resident with multiple medical conditions and intact cognition was not assessed for smoking safety, and their care plan did not address smoking, despite facility policy requiring such assessments. Staff provided cigarettes and assisted the resident with smoking without a documented evaluation of the resident's ability to smoke safely.
A resident with end-stage renal disease and dependent on dialysis did not have required post-dialysis assessments completed and documented on multiple occasions, despite physician orders and facility policy. Nursing staff and the DON confirmed that these assessments were expected on each dialysis day, but several dates were identified where documentation was missing.
Three residents with cognitive deficits and swallowing difficulties were served regular corn instead of the scheduled vegetable, despite being on mechanical soft diets. The dietary aide was unaware that regular corn was not suitable for these diets, and a delay in updating diet orders further contributed to the deficiency. The facility's policy requiring physician-specified therapeutic diets was not consistently followed.
A resident with significant mobility needs developed a pressure ulcer on the right heel that progressed from a bruise to an open wound and then to a stage 3 ulcer. Facility staff did not apply any treatment or dressing to the wound for eight days, despite recognizing the change in condition, and failed to notify the primary provider or obtain wound care orders until the visiting wound care nurse assessed the wound. Communication lapses and lack of adherence to wound care policy contributed to the delay in care.
The facility experienced delays in responding to resident call lights, with some residents waiting up to an hour for assistance. Observations and resident complaints highlighted extended wait times, often due to staffing shortages. Staff interviews confirmed that call light responses could exceed 15 minutes when understaffed, despite the facility's policy emphasizing timely responses.
The facility failed to complete physician's orders for two residents, leading to deficiencies in care. A resident with no cognitive impairment did not receive a timely strep test, while another with severe cognitive impairment had delayed wound care and consults. The DON was on vacation, and there was inadequate follow-up by the ADON, resulting in missed and delayed orders.
The facility failed to provide adequate incontinence care for three residents dependent on staff for ADLs. A resident was left in soiled clothing overnight, another indicated inconsistent bedding changes, and a third reported delays in being cleaned up. Staff interviews confirmed residents were often found soaked after the overnight shift, highlighting a pattern of neglect in timely care.
The facility failed to prevent and properly treat pressure ulcers for two residents. One resident developed a heel ulcer that worsened due to delayed treatment and inconsistent use of Prevalon boots, leading to hospitalization. Another resident with a chronic pressure area did not receive the recommended barrier creams after incontinence episodes, contrary to the care plan. These deficiencies highlight the facility's failure to adhere to care plans and physician orders, resulting in the deterioration of residents' conditions.
A facility failed to follow physician orders and provide timely incontinence care for two residents. One resident, with a UTI and septicemia, experienced delays in diagnosis and treatment due to inadequate communication and order execution. Another resident, dependent on staff for toileting, was found with soaked protective pads and soiled shorts, indicating a lack of timely care. The facility's policy required regular toileting assistance, which was not consistently provided.
The facility failed to serve food at appropriate temperatures to several residents, as reported by residents and confirmed by temperature checks. A resident stated that food was often cold, and another mentioned that the kitchen manager did not address complaints. Temperature checks showed food below expected temperatures, and staff interviews indicated delays in food delivery. The facility's policy required maintaining proper food temperatures, which was not followed.
The facility failed to follow proper sanitation and food handling practices, as staff members did not adhere to hand hygiene protocols and served food without appropriate coverings. Staff with facial hair did not wear required coverings, and ice was added to beverages using glasses instead of scoops, contrary to facility policies.
A facility failed to update the PASRR for a resident diagnosed with new mental health disorders, including anxiety, depression, and PTSD. Despite these diagnoses, the PASRR was not revised, and the oversight was acknowledged by staff during interviews. The facility lacked a policy for updating PASRRs when residents received new mental health diagnoses.
A facility failed to maintain accurate medical records for a resident on enteral feeding, as several instances of unsigned MARs were found. The resident reported occasional delays in starting feedings, which were confirmed by staff interviews. Despite these delays, the resident did not miss any feedings. The facility's policy required documentation of medication administration, which was not consistently followed.
The facility failed to provide adequate hand hygiene and Enhanced Barrier Precautions (EBP) for three residents. A resident with intact cognitive ability did not receive proper glove changes during incontinence care. Another resident with renal issues and a permacath did not have PPE used during a post-dialysis assessment. A third resident with an indwelling catheter did not have a gown applied during catheter care. Facility policies and CDC guidelines were not followed.
A resident reported missing money to staff, but the grievance was not documented or resolved for several months. The facility's grievance policy was not followed, leading to a failure to address the resident's concerns promptly.
Failure to Prevent Financial Exploitation of a Resident by Facility Staff
Penalty
Summary
A resident with a history of anemia, renal failure, bipolar disorder, respiratory failure, and a stage 3 sacral pressure ulcer, and who was assessed as cognitively intact with a BIMS score of 15, was involved in multiple financial transactions with a Certified Nursing Assistant (CNA) employed by the facility. The resident's care plan noted a risk for impaired cognitive function or thought processes, but the resident was his own payee and managed his own finances. The CNA was observed in the resident's room while the resident had his wallet out, and subsequent interviews revealed that the resident had given the CNA money on two separate occasions. The first incident occurred when the CNA complained to the resident about personal financial difficulties, specifically needing to fix her car battery. The resident gave the CNA $100, expecting repayment. The CNA later attempted to repay a portion of the money, but the resident declined partial repayment, requesting the full amount instead. On a subsequent occasion, the CNA informed the resident of a domestic situation, and the resident gave her an additional $12. The resident did not initially report these transactions, stating he willingly lent the money and would consider it a loss if not repaid. Facility staff became aware of the situation when the Assistant Administrator observed the CNA with the resident and his wallet. Upon inquiry, the resident confirmed giving money to the CNA. The CNA denied accepting any money from the resident. The facility's review of timecards indicated the CNA was not scheduled to work on the days the transactions occurred, but she had been present in the facility. The facility's policies prohibit staff from accepting money from residents, and the CNA had signed documents acknowledging these policies. The events were reported to local authorities, but no criminal charges were filed as the resident was deemed to have willingly given the money.
Failure to Maintain a Safe Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Complete Required Assessments and Medication Self-Administration Reviews
Penalty
Summary
The facility failed to complete required assessments and follow professional standards of practice for three residents. Two residents, both with no cognitive impairment and physician orders for self-administered medications (albuterol inhalers and topical powder), were observed to have these medications at their bedside and reported self-administering them. However, there was no documentation of a medication self-administration assessment or a care plan addressing self-administration for either resident. The DON confirmed that no assessments had been completed and acknowledged that medications should not have been left in the residents' rooms without such assessments, as required by facility policy. Another resident with severe cognitive impairment and a history of falls experienced a witnessed and an unwitnessed fall, the latter resulting in a left hip fracture. After the unwitnessed fall, the resident initially complained of pain, but this was not consistently documented or communicated among staff. Although the physician was notified and indicated that an x-ray should be obtained if needed, this instruction was not documented in the written shift exchange, and subsequent staff were unaware of it. The resident continued to have pain and increased bruising, which was reported to nurses but not fully assessed or documented. An x-ray confirming the fracture was not obtained until several days later, after ongoing pain and functional decline were noted. Facility policy required ongoing assessment and documentation for 72 hours after a fall, including monitoring for changes in pain, mobility, swelling, and bruising. The staff did not consistently follow this policy, as changes in the resident's condition and new bruising were not fully assessed or investigated. The DON and Administrator acknowledged that changes in pain and new bruising should have prompted further assessment and communication with the physician, and that the transition to hospice care should not have altered the standard of care provided.
Repeat Deficiencies in QAPI, Pressure Ulcer Prevention, and Infection Control
Penalty
Summary
The facility failed to provide a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeat deficiencies in the areas of pressure ulcer prevention and treatment, and infection control. The facility had a census of 86 residents and had previously been cited for these same issues during annual surveys and complaint investigations. The Administrator acknowledged that Enhanced Barrier Precautions (EBP) had not been reviewed or addressed in Quality Assurance meetings, and that pressure ulcer prevention and treatment remained an ongoing challenge. Facility policy required a data-driven, facility-wide QAPI program with monthly committee meetings to review reports and make adjustments, but these processes were not effectively implemented or followed, as indicated by the repeat deficiencies.
Failure to Implement Enhanced Barrier Precautions and Infection Control Measures
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) for multiple residents with conditions requiring such precautions. For a resident with renal insufficiency, a multidrug-resistant organism (MDR), and wounds, staff did not change gloves or perform hand hygiene between tasks and failed to wear gowns as required by EBP during repositioning and wound care. Similarly, another resident with an indwelling catheter and positive MRSA status was transferred and repositioned by staff who did not change gloves or perform hand hygiene, and did not wear gowns as required. Staff interviews confirmed awareness of the need for gowns and proper hand hygiene, but these practices were not followed during observed care. In another case, a resident with a chronic vascular ulcer and EBP orders for wounds received wound care from an LPN who inconsistently performed hand hygiene between glove changes and used paper towels instead of a chuck pad as a barrier for dressing supplies. The LPN also used sanitized scissors to cut through dressing packaging, which was not in line with facility expectations. The resident reported that only certain staff wore gowns during treatments, and interviews with staff revealed confusion about EBP signage and inconsistent use of PPE prior to the current week. A further deficiency was observed with a resident who had a stage 4 pressure ulcer and was on EBP for wounds. During wound and peri care, an RN did not consistently perform hand hygiene between glove changes, used improper techniques for cleansing and ointment application, and required reminders from another staff member to use a gown and perform hand hygiene. Facility policy and staff interviews confirmed that hand hygiene should be performed after glove removal and between tasks, and that PPE should be used as indicated by EBP orders, but these protocols were not consistently followed during the observed care.
Failure to Provide Timely Response to Resident Call Lights
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to resident call lights, resulting in delays for multiple residents. Observations, interviews, and call light log reviews revealed that several residents experienced wait times exceeding 15 minutes on numerous occasions when requesting assistance. For example, one resident with diabetes, end stage renal disease, and vascular dementia reported that it often took longer than 15 minutes for staff to respond to her call light, with documented instances of response times ranging from 16 to 45 minutes over several days. The resident also stated that staff told her they did not have time to assist her with being put to bed. Another resident with hemiplegia, muscle weakness, and anxiety disorder was observed waiting over 15 minutes for assistance to use the toilet, despite staff being aware of her need. The call light log for this resident also showed multiple instances of delayed responses, some exceeding 40 minutes. Staff interviews confirmed that the facility's expectation was to answer call lights within 15 minutes, but acknowledged that this standard was not consistently met. The DON and Administrator both stated that call lights should be answered as soon as possible, and that grievances regarding call light response times had been received. Additional residents reported similar experiences, including one who had to wait 45 minutes on the toilet during a shift change and another who stated that call lights frequently took over 15 minutes to be answered. The facility's policy requires staff to answer call lights in a timely manner, but the documented delays and resident reports indicate that this policy was not consistently followed, resulting in unmet care needs for several residents.
Failure to Follow Physician Orders for Medication and Wound Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents, specifically by not following physician orders for medication administration and wound care. One resident was admitted with multiple diagnoses, including heart failure, renal insufficiency, diabetes, anxiety disorder, and respiratory failure. Upon admission, the resident did not receive any of the prescribed evening medications, and there was no documentation that the physician was notified of the missed doses. The medication orders were not faxed to the pharmacy until later in the evening, resulting in a delay in medication delivery. The resident and a family member reported that medications were not administered and that the resident's oxygen tank ran out without timely replacement, prompting the resident to leave the facility against medical advice the following day. Another resident with a history of coronary artery disease, heart failure, and peripheral vascular disease had a care plan addressing the risk for pressure ulcer development and a chronic vascular ulcer on the right lower leg. The facility staff did not consistently follow wound care orders as written by the resident's provider, including the application of dressings and compression stockings. Observations and staff interviews revealed that wound care treatments were missed or performed incorrectly, with staff citing time constraints and lack of specific training. Documentation showed that the resident experienced increased edema, wound deterioration, and episodes of cellulitis, with inconsistent use of compression stockings and incorrect dressing applications. Multiple progress notes and interviews with external care providers indicated ongoing concerns about the facility's compliance with wound care orders. The facility's own policies required that physician orders be followed and that the DON or designee and physician be notified if orders could not be carried out. Despite this, there were repeated failures to adhere to prescribed treatments, and the DON and administrator acknowledged missed treatments and lack of staff education. The deficiencies were substantiated by clinical record reviews, resident and family interviews, pharmacy and staff interviews, and policy review.
Failure to Provide Timely Toileting Assistance Compromising Resident Dignity
Penalty
Summary
A deficiency occurred when staff failed to provide timely toileting assistance to a resident with no cognitive impairment, as indicated by a BIMS score of 15, and diagnoses including hemiplegia, hemiparesis, anxiety disorder, and generalized muscle weakness. The resident, who required assistance with personal care, activated her call light to request help with toileting. Staff entered the room, acknowledged her request, and stated they would return to assist her, but the call light was turned off and the resident was left waiting for more than 15 minutes. During this period, staff communicated the resident's need to other staff members, but no one responded promptly to her request. The resident reported that it frequently took longer than 15 minutes for staff to answer her call light, and on this occasion, she waited approximately 30 minutes before receiving assistance, resulting in incontinence. The resident expressed feelings of embarrassment, shame, sadness, and a lack of dignity due to the delay and subsequent incontinence. Staff interviews confirmed the delay exceeded the facility's expectation for call light response times, and the facility's policy emphasized the importance of prompt response to promote resident dignity and well-being.
Failure to Include Diuretic Use in Comprehensive Care Plan
Penalty
Summary
The facility failed to provide a comprehensive care plan addressing the use of high-risk medications for one resident who had a physician's order for daily diuretic therapy. Clinical document review showed that the resident had diagnoses including cancer, diabetes mellitus, and hyperlipidemia, and was receiving Furosemide 20 mg daily. However, the resident's care plan, last revised on 5/21/25, did not include any documentation regarding the use of diuretics. Staff interview with the DON confirmed that diuretic use should have been included in the care plan. Facility policy requires ongoing assessment and revision of care plans as resident conditions change, but this was not followed for the resident in question.
Failure to Assess Resident for Smoking Safety
Penalty
Summary
The facility failed to assess a resident for safety while smoking, as required by their own policy. Clinical record review showed that the resident, who had intact cognition and multiple diagnoses including hypertension, peripheral vascular disease, renal failure, respiratory failure, and an above-the-knee amputation, used tobacco products. Despite this, there was no documentation of a smoking assessment in the resident's electronic health record, nor was smoking addressed in the resident's care plan. Progress notes indicated that the resident requested cigarettes and a lighter for an appointment, and staff reviewed the smoking policy with the resident, but no formal assessment was completed. Observation revealed that staff provided cigarettes and a lighter to the resident and assisted with lighting and disposing of cigarettes during a smoking period. Interviews with the DON and Administrator confirmed that a smoking assessment should have been completed and included in the care plan, in accordance with facility policy, which requires evaluation of smoking status on admission and routine re-evaluation of the ability to smoke safely. The lack of assessment and care planning for smoking safety constituted the deficiency.
Failure to Complete Post-Dialysis Assessments for Resident Receiving Dialysis
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards by not completing post-dialysis assessments for a resident who required such care. Review of the electronic health records (EHR) for a resident with end-stage renal disease and dependence on renal dialysis revealed multiple instances over a 60-day period where post-dialysis assessments were not documented, despite physician orders requiring complete pre- and post-dialysis vital signs, weight, and evaluation. The resident was cognitively intact and attended dialysis three times weekly as scheduled. Interviews with nursing staff, including LPNs, an RN, and the Director of Nursing (DON), confirmed that pre- and post-dialysis assessments were expected to be completed and documented on each dialysis day. The DON acknowledged that the identified dates lacked the required post-dialysis assessments and stated that her expectation was for these assessments to be completed and charted in the appropriate sections of the EHR. Facility policy also required staff to be educated and trained on the specific assessment data to be gathered for residents receiving dialysis.
Failure to Provide Appropriate Mechanically Altered Diets
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of residents requiring mechanically altered diets. During a lunch service, the dietary staff ran out of the scheduled vegetable, broccoli, and substituted corn for residents on mechanical soft diets. The dietary aide/cook was not aware that regular corn is not suitable for mechanically soft diets, and served it to three residents with orders for mechanical soft diets. The dietician later confirmed that only creamed corn would be acceptable for such diets, not regular corn. The residents affected included individuals with severe to moderate cognitive deficits, swallowing difficulties, and risks for nutritional deficits. Their care plans and physician orders specified the need for mechanical soft diets due to conditions such as dysphagia and Alzheimer's disease. Additionally, there was a delay in updating dietary orders following a change in one resident's diet texture, as communication from speech therapy to nursing was not transcribed in a timely manner. The facility's policy required that therapeutic diets be prescribed and specified by the attending physician, but this was not consistently followed.
Failure to Provide Timely Pressure Ulcer Treatment and Prevention
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and adequate treatment and interventions to prevent the worsening of a pressure ulcer for one resident. The resident, who required significant assistance with mobility and transfers, developed an open area on the right heel that was initially identified as a bruise. Over time, the area progressed to a stage 2 pressure ulcer, and later to a stage 3 ulcer with necrotic tissue and slough. Despite the change in the wound's condition, no treatment or dressing was applied to the right heel for eight days, from the time the area became open until the visiting wound care nurse assessed the wound and initiated treatment orders. Documentation and interviews revealed that the facility staff recognized the change in the wound on the right heel, including the presence of a blister, crack, and drainage. The Director of Nursing (DON) and other staff acknowledged that the area was not just a bruise but had become an open wound. However, there was no evidence that the primary physician was notified or that a request for wound treatment was made during this period. The wound care nurse, upon arrival, noted that the wound was unstageable due to eschar and slough, and expressed concern that no dressing or treatment had been started prior to her visit. The resident was observed resting the affected heel on the bed frame without protective boots, further contributing to the pressure and injury. The facility's own policies required physician notification and wound care orders for abnormalities such as wounds, but these steps were not followed. Communication lapses between facility staff and providers contributed to the delay in care, as the resident's primary provider was not informed of the wound's progression. Staff interviews confirmed that no dressing or treatment was applied to the open area until the wound care nurse's assessment, despite the wound being at least a stage 2 ulcer at the time it became open.
Delayed Call Light Responses Due to Staffing Issues
Penalty
Summary
The facility failed to provide timely responses to resident call lights, as evidenced by multiple observations and resident complaints. On specific occasions, call lights were activated for extended periods, such as 23 and 22 minutes, before being addressed by staff. Resident council notes and grievance logs consistently documented concerns about delayed call light responses over several months, with residents expressing dissatisfaction with the time it took for staff to respond. Interviews with residents revealed that some experienced wait times of up to an hour, leading to incidents such as accidents due to delayed assistance. Staff interviews indicated that staffing shortages contributed to the delays in responding to call lights, with CNAs acknowledging that response times could exceed 15 minutes when the facility was understaffed. The facility's administrator and Director of Nursing were aware of the issue, with the administrator noting the lack of means to pull call light response time reports. The facility's policy, revised in September 2022, emphasized the importance of timely responses to call lights, yet the observed and reported delays suggest a failure to adhere to this policy consistently.
Failure to Complete Physician's Orders for Two Residents
Penalty
Summary
The facility failed to complete physician's orders for two residents, leading to deficiencies in care. Resident #3, who had no cognitive impairment, was ordered tests for strep, flu, and COVID-19 by the ARNP due to a sore throat. However, the strep test was not completed on the same day as ordered, and there was confusion regarding the test panel used, which did not include the strep test. Despite multiple follow-ups by the ARNP, the test was delayed, although the resident's symptoms resolved without treatment. Resident #4, who had severe cognitive impairment, had a left heel wound that required a wound culture, wound care consult, and duoderm dressing as ordered by the ARNP. The wound culture was delayed, and the duoderm dressing was not initiated as ordered. The wound care consult was not set up, and the resident's condition worsened, leading to hospitalization and subsequent hospice care. The DON acknowledged the oversight and attempted to address the issue, but the consult was not completed before the resident's hospitalization. The facility's process for handling physician orders was inadequate, leading to missed and delayed orders. The DON was on vacation during the time of the deficiencies, and there was a lack of follow-up by the ADON. The facility's policy on medication and treatment orders was not followed, resulting in the deficiencies noted in the report.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide adequate assistance to three residents who were dependent on staff for Activities of Daily Living (ADLs) care, specifically when they were incontinent of urine and/or bowel. Resident #5, who had no cognitive impairment and was frequently incontinent of bowel, reported that she was left in soiled clothing overnight despite requesting assistance. Her care plan indicated she required substantial assistance for bed mobility and was dependent on staff for toilet hygiene, yet she was not adequately attended to. Resident #7, with mild cognitive impairment and a history of stroke, was always incontinent of urine and frequently incontinent of bowel. He required assistance from staff for bed mobility and toileting. Despite this, he indicated that there were times when his bedding needed changing due to incontinence, suggesting inconsistent care. His care plan directed staff to ensure he was clean and dry with each check and change, which was not consistently followed. Resident #8, who had no cognitive impairment and was always incontinent of bowel and bladder, reported having to wait approximately 30 minutes to be cleaned up after becoming incontinent at night. Staff interviews revealed that residents were often found soaked in urine or feces after the overnight shift, indicating a pattern of neglect in providing timely incontinence care. The Director of Nursing acknowledged the issue and mentioned efforts to address it, but the deficiency persisted, affecting the residents' dignity and comfort.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement timely and appropriate interventions to prevent the worsening of pressure sores for two residents. Resident #16 developed a pressure sore on her heel, which was not promptly treated according to physician orders. The staff delayed the application of prescribed treatments and failed to use the recommended Prevalon boots consistently, which are essential for off-loading pressure from the heel. The wound care nurse practitioner noted that the resident's wound deteriorated rapidly, with increased pain, odor, and slough, indicating infection. Despite the worsening condition, the staff did not report these changes promptly, and the resident was eventually hospitalized for further treatment. Resident #17, who was dependent on staff for dressing and toileting, had a chronic pressure area on his buttocks. The staff failed to apply the recommended barrier creams after each incontinence episode, as outlined in the care plan. During an observation, CNAs did not apply barrier cream to the resident's reddened spots and open area on the thigh, despite the resident's complaint of pain. The facility's policy on pressure injury prevention, which includes the use of barrier products to protect the skin from moisture, was not followed. The facility's failure to adhere to care plans and physician orders, along with inadequate communication among staff, contributed to the deterioration of the residents' conditions. The lack of timely intervention and proper use of pressure-relieving devices and barrier creams resulted in the worsening of pressure sores, leading to increased pain and infection for the residents involved.
Failure to Follow Physician Orders and Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide a professional standard of quality care by not following physician orders and failing to maintain continence for two residents. Resident #61, who had a BIMS score indicating no cognitive deficit, was diagnosed with a urinary tract infection (UTI) and septicemia. Despite having an indwelling catheter, the facility did not rate urinary continence. The resident's care plan included monitoring for signs of UTI and incontinence, but the facility did not act promptly when the resident's daughter reported symptoms of a UTI. The nurse faxed a request for a urinary analysis (UA) instead of calling the on-call provider, leading to delays in diagnosis and treatment. The resident was eventually hospitalized for acute kidney injury, pneumonia, and UTI. Resident #17, with a BIMS score indicating intact cognitive ability, was totally dependent on staff for dressing and toileting hygiene. The resident was frequently incontinent of urine and always incontinent of bowel due to a neurogenic bladder and spinal cord injury. Despite the care plan directing staff to apply barrier cream and monitor for incontinence, the resident was found with soaked protective pads and soiled shorts, indicating a lack of timely incontinence care. Staff reported that the resident had stopped asking for help with the urinal, leading to increased incontinence. The facility's failure to follow physician orders and provide timely incontinence care resulted in significant health issues for both residents. The Director of Nursing acknowledged a breakdown in communication and order completion, which contributed to the deficiencies. The facility's policy required staff to offer toileting assistance every two hours, but this was not consistently followed, leading to the residents' deteriorating conditions.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food at an appetizing temperature to four residents, as observed through resident interviews, staff interviews, and resident council notes. Resident #52, with no cognitive impairment, reported that the food was often cold when it should be warm. Resident #59, also with no cognitive impairment, stated that corn dogs were served cold and that the kitchen manager did not listen to complaints about the food. Resident #59 further mentioned that food was frequently cold and that many residents complained about the food during monthly meetings. A temperature check of a meal intended for Resident #59 revealed that the beef stroganoff was at 132 degrees and the brussels sprouts at 111 degrees, which was below the expected temperature. Resident #25, who required setup for meals and had no cognitive deficit, reported that the food was often cold and the pasta was mushy. Resident #61, also with no cognitive deficit, stated that meals were not always hot and left most of her food uneaten because it was not hot enough. Staff interviews revealed that the dietary cart had been out of the kitchen for about 20 minutes before a temperature check was conducted. The facility's policy on food preparation and service indicated that proper hot and cold temperatures should be maintained during food service, but this was not adhered to, leading to the deficiency.
Failure to Follow Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to adhere to proper sanitation, food safety, and food handling practices as observed during a survey. Staff members, including cooks and dietary aides, were noted to have facial hair without appropriate coverings, contrary to the facility's policy requiring hair and beard restraints. Observations revealed that food items were served without proper coverings, and staff members did not consistently perform hand hygiene before and after glove use or when entering the kitchen. Specifically, a cook and dietary aides were seen handling food and trays without following hand hygiene protocols, and one dietary aide used individual glasses instead of a scoop to add ice to beverages. The facility's policies on food preparation and hand hygiene, revised in 2019, were not followed by the staff. These policies require hand hygiene before serving food, after handling soiled items, and before and after glove changes. Additionally, food and drink items for delivery should be covered, and staff must use scoops for ice. The dietary manager confirmed these requirements and acknowledged the lapses in adherence to the policies. The facility reported a census of 65 residents at the time of the survey.
Failure to Update PASRR for Resident with New Mental Health Diagnoses
Penalty
Summary
The facility failed to complete a Pre-Admission Screening and Resident Review (PASRR) for a resident who was diagnosed with new mental disorder diagnoses since admission. The resident, identified as Resident #25, had a Minimum Data Set (MDS) assessment indicating no cognitive deficit and was diagnosed with anxiety disorder, depression, and post-traumatic stress disorder (PTSD). Despite these diagnoses, the facility's PASRR Notice of Nursing Facility Approval did not reflect the need for PASRR intervention, and the screen was considered valid for the resident's stay. However, the resident's electronic health record revealed additional diagnoses of generalized anxiety disorder, PTSD, insomnia, and major depressive disorder, with corresponding physician orders for medications. During interviews, facility staff acknowledged the oversight in updating the PASRR for Resident #25. The Social Service Designee admitted that the new diagnoses had been missed, and a new PASRR had not been completed. The facility administrator further explained that an audit conducted 6-9 months prior had identified a need for multiple PASRR updates due to unnotified additions of diagnoses by a provider. The facility lacked a policy for updating PASRRs when residents received new mental health diagnoses, leading to the deficiency in Resident #25's case.
Incomplete Documentation of Enteral Feeding Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident requiring enteral feeding, as evidenced by unsigned medication administration records (MAR) and treatment administration records (TAR) over several months. The resident, who had no cognitive impairment, reported that the evening nurse sometimes forgot to turn on the feeding pump, which was then discovered by the morning nurse. Despite these lapses, the resident stated she did not miss any feedings. Staff interviews revealed inconsistencies in the documentation process, with some nurses admitting to not signing the MAR when feedings were administered outside the scheduled times. The Director of Nursing (DON) confirmed that the facility's policy required nurses to document in the MAR and enter a progress note if feedings were not started or delayed. However, the policy was not consistently followed, leading to gaps in the records. The facility's policy on administering medications required the individual administering the medication to sign the MAR with their signature and title, which was not adhered to in this case. This deficiency was identified through resident and staff interviews, as well as a review of the electronic health records and facility policies.
Inadequate Infection Control and EBP in LTC Facility
Penalty
Summary
The facility failed to provide adequate hand hygiene and Enhanced Barrier Precautions (EBP) for three residents. For Resident #17, who had a BIMS score of 15 and was dependent on staff for dressing and toileting hygiene, staff did not change gloves during incontinence care. Staff A and Staff B, both CNAs, were observed transferring the resident and providing care without changing gloves after wiping feces, which is against the expected protocol as stated by the Director of Nursing (DON). Resident #25, with a BIMS score of 15 and diagnosed with renal insufficiency and a multidrug-resistant organism (MDRO), required EBP due to a permacath. During a post-dialysis assessment, Staff J, an LPN, did not utilize any PPE, including gown, gloves, or mask, despite the resident's increased risk for infection. The facility's policy and the DON's statement indicated that EBP should have been followed, especially given the resident's indwelling medical device. For Resident #21, who had a BIMS score of 10 and an indwelling catheter, Staff B, a CNA, did not apply a gown during catheter care, although gloves were used. The facility's policy and the DON's statement confirmed that gowns and gloves should have been worn during such procedures. The Centers for Disease Control and Prevention guidelines also support the use of EBP for residents with indwelling medical devices, regardless of MDRO colonization status.
Failure to Address Resident Grievance Promptly
Penalty
Summary
The facility failed to promptly address a grievance reported by a resident, who had no cognitive impairment as indicated by a BIMS score of 15. The resident reported missing money and tickets to two staff members, the Social Service Designee and the Business Office Manager. Despite the resident's report, no grievance was filed, and the issue was not resolved. The Social Service Designee was unaware of the missing money, and the Business Office Manager acknowledged the resident's report but did not follow through with the grievance process, assuming someone else would handle it. This lack of action led to the resident's grievance being unaddressed for several months. The facility's grievance policy requires staff to complete a Grievance Report Form when a grievance is not immediately resolved, but this procedure was not followed. The Administrator was unaware of the incident until much later and stated that the facility would replace the missing money. The policy review indicated that the grievance should have been documented and investigated, but this did not occur, resulting in a failure to uphold the resident's right to voice grievances without reprisal or discrimination.
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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