Azria Health Park Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Des Moines, Iowa.
- Location
- 2401 East Eighth Street, Des Moines, Iowa 50316
- CMS Provider Number
- 165202
- Inspections on file
- 29
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 24 (1 serious)
Citation history
Health deficiencies cited at Azria Health Park Place during CMS and state inspections, most recent first.
The facility failed to maintain kitchen sanitation and pest control, resulting in extensive water damage, pest infestations, and unsanitary food storage and preparation areas. Staff reported daily sightings of mice, cockroaches, and flies, with years of accumulated grime and recurring flooding making cleaning difficult. Cleaning logs were missing or outdated, and multiple residents and staff experienced gastrointestinal symptoms, including diarrhea and vomiting, which some attributed to the food served. Food containers were found contaminated with mouse droppings and dead maggots, and expired food was served to residents.
Surveyors found the facility failed to provide a clean, comfortable, and homelike environment, with observations of mold, musty odors, soiled mattresses and linens, water damage, and pest activity. There were repeated shortages of appropriately sized briefs, gloves, wipes, and linens, leading staff to use makeshift solutions and leaving residents in soiled conditions. Staff and residents reported infrequent cleaning, persistent odors, and confusion over cleaning responsibilities, all contributing to an environment that did not meet required standards.
The facility did not provide enough nursing staff to meet residents' needs for toileting and timely call light response, resulting in multiple residents waiting extended periods for assistance, including one left on the toilet for half an hour and another in a soiled brief. Staff and resident interviews, as well as facility records, confirmed frequent delays and inadequate staffing, with reliance on agency and management staff to fill gaps. Call light response times often exceeded the expected 15 minutes, and ongoing concerns were documented in resident council meetings and grievance logs.
Facility leadership failed to ensure adequate supplies of incontinence products and linens, resulting in staff using makeshift solutions for resident care. Multiple staff and residents reported persistent shortages, unclean resident rooms, and a kitchen infested with mice, cockroaches, and flies. The kitchen and other facility areas suffered from structural disrepair, flooding, and foul odors, with management often unaware or unresponsive to ongoing issues reported by staff.
The facility was repeatedly cited for infection control and homelike environment deficiencies, with QAPI meeting minutes showing ongoing discussion of the same issues without documented follow-through or resolution. The DON could not explain the lack of follow-through, and the RDO confirmed that previous leadership did not implement the QAPI plan as required.
Staff failed to follow infection control protocols during resident transfers and incontinence care, including not changing gloves or sanitizing hands between tasks, using a mechanical lift sling from another resident's room without sanitizing it, and not utilizing Enhanced Barrier Precautions for a resident with an indwelling catheter. These actions were inconsistent with facility policy and standard precautions.
Staff failed to lock bed brakes while providing care to a resident with significant mobility impairments, resulting in the bed moving and the resident expressing fear of falling. Additionally, staff did not follow manufacturer instructions for mechanical lift use during transfers for two residents, including improper sling attachment and incorrect positioning of the lift's leg bar. Facility policies and competency checks were found lacking in guidance and oversight for safe transfer practices.
The facility failed to protect residents from abuse, as evidenced by incidents involving rough handling and threatening behavior by a CNA. Despite complaints, the CNA continued to work without immediate suspension or investigation. The facility's delayed response and inadequate implementation of abuse policies placed residents at risk.
The facility failed to maintain a homelike environment by allowing clutter in the hallways of both the North and South Halls, leading to safety hazards and resident conflicts. Equipment such as mechanical lifts, carts, and wheelchairs obstructed passage, causing residents in wheelchairs to argue and staff to intervene. A surveyor also tripped over an open mechanical lift leg. The facility lacked specific policies for equipment storage and wheelchair transport, contributing to the unsafe conditions.
The facility was found to have significant sanitation and food safety deficiencies. Staff were observed handling food without proper hygiene, such as not washing hands and using bare hands to serve food. The kitchen had unsanitary conditions, including unlabeled and undated food items, improper hair net usage, and broken equipment. A container of strawberries was found spoiled, indicating poor adherence to food storage policies. The dietician and DON confirmed the need for proper sanitation practices.
The facility failed to report abuse allegations involving three residents in a timely manner, leading to an Immediate Jeopardy situation. One resident reported rough treatment during pericare, while another was allegedly handled roughly and threatened by a CNA during a transfer. Delays in reporting these incidents to authorities violated facility policies and placed residents at risk.
The facility experienced significant delays in responding to resident call lights, with documented response times often exceeding 20 minutes and sometimes extending over an hour. Resident council meetings and interviews highlighted ongoing concerns about these delays, particularly during weekends and night shifts. Despite efforts to maintain adequate staffing and improve response times, the facility's policy expectation of answering call lights within 15 minutes was not consistently met.
The facility failed to provide required Medicare Liability Notices and Beneficiary Appeals forms to three residents within the mandated 48-hour window after the end of skilled services. Two residents did not receive the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN), and one resident's SNFABN lacked the necessary cost disclosure.
A facility failed to accurately document a resident's discharge destination in the MDS assessment, indicating a hospital discharge instead of a community setting. The error was acknowledged by the Social Worker, who suggested it might have been due to the resident's initial hospital admission.
A facility failed to update the PASRR level 1 screening for a resident with moderate cognitive impairment and multiple diagnoses, including a delusional disorder. The resident's care plan and medication records indicated changes in treatment that required a new PASRR screening, which was not submitted. The oversight was acknowledged by the facility's social worker and regional nurse consultant.
The facility failed to track and document behaviors for residents on psychiatric medications, leading to discrepancies in records. A resident with moderate cognitive impairment and multiple diagnoses was on antipsychotic therapy, but the care plan lacked specific behavioral interventions. Another resident with similar impairments had inconsistent documentation of behaviors in the MAR and EHR. A third resident with intact cognition had discrepancies between nursing notes and the EHR. Staff interviews revealed a lack of awareness of behavior monitoring duties.
A resident with Diabetes Mellitus did not receive insulin correctly due to an LPN's failure to follow proper procedures. The LPN did not prime the insulin pen, hold it to the skin for the recommended time, or perform hand hygiene. Interviews with staff confirmed these steps were not followed, which could result in incomplete medication administration.
Widespread Kitchen Sanitation and Pest Control Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a safe and hygienic manner, resulting in unsanitary conditions and pest infestations. Direct observations revealed significant water damage in the kitchen and basement, including missing and collapsing ceiling tiles, moist surfaces, and water beading near food preparation areas. The kitchen floor was covered in sticky substances and food particles, with blackened grout in high-traffic areas. Multiple sticky traps containing rodent droppings, fur, and insects were found near dry storage, and peaches past their expiration date were served to residents. Small worm-like insects and insect eggs were observed in floor drains filled with food debris, and rodent droppings were found under and in front of the oven. Mold-like substances were present on sponges and in floor drains, and kitchen equipment was covered in grime. Unlabeled and open bags of food were found in freezer units. Staff interviews confirmed ongoing issues with rodents, cockroaches, ants, and flies in the kitchen, with several staff members reporting daily sightings of mice and expressing frustration over the lack of management response. Staff described the kitchen as extremely dirty and difficult to clean, with years of accumulated grime and recurring flooding during heavy rain. Cleaning logs were missing or incomplete, with the last documented logs dating back several months. The pest control contractor's records noted ongoing sanitation issues, such as standing water and accessible garbage, but did not document pest activity, which was inconsistent with staff and resident reports. The dietary manager and other staff confirmed frequent rodent activity, including the discovery of mouse nests and droppings in food storage areas. Residents and staff reported an increase in gastrointestinal symptoms, including diarrhea and vomiting, over the past month. Several residents and staff attributed these symptoms to the food served at the facility, with some residents reporting persistent diarrhea since admission. The infection preventionist did not track single-day episodes of gastrointestinal symptoms, but surveillance records documented multiple cases of diarrhea, vomiting, and abdominal pain, including one resident hospitalized with colitis. The kitchen and storage areas were found to have food containers contaminated with mouse droppings, dead maggots, and sticky residues, further indicating a failure to protect food from contamination and maintain sanitary conditions.
Failure to Maintain Clean, Homelike Environment and Adequate Resident Care Supplies
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of unsanitary and unsafe conditions throughout the building. Surveyors noted the presence of black substances resembling mold and dirt in air conditioning vents, musty odors, missing wall bases, stained and soiled mattresses and linens, and evidence of water damage such as caved-in ceilings and water-stained walls. The North and South Halls, shower rooms, laundry, and basement areas all exhibited significant cleanliness and maintenance issues, including cracked tiles, biofilm in drains, missing non-skid strips, and the presence of mouse droppings and flies. Residents and staff reported persistent odors of urine and infrequent cleaning of rooms and equipment, with some residents lying in soiled beds and reporting that their rooms were not cleaned regularly. The facility also failed to maintain adequate supplies of personal care items and linens. Observations revealed repeated shortages of appropriately sized briefs, gloves, cleansing wipes, and linens in both the North and South Hall supply rooms, as well as the central supply area. Staff interviews confirmed that shortages were frequent, with staff sometimes resorting to makeshift solutions such as stapling briefs together or using washcloths in place of wipes. Staff reported that supplies often ran out before new shipments arrived, and that communication about supply needs did not always result in timely restocking. Residents corroborated these accounts, stating that they were sometimes left in soiled conditions due to lack of supplies, and that the facility often ran short on briefs and other essentials, especially toward the end of the week. Interviews with staff and residents further highlighted the impact of these deficiencies. Residents described being dressed in wet beds, smelling of urine, and seeing mice in their rooms. Staff reported confusion over responsibilities for cleaning mattresses and equipment, and housekeeping staff indicated that they did not clean mattresses or strip linens. The facility's policies required a clean, sanitary, and homelike environment, but observations and interviews demonstrated that these standards were not being met. The lack of adequate supplies and poor environmental maintenance directly contributed to the failure to honor residents' rights to a safe and comfortable living environment.
Failure to Provide Sufficient Staff for Timely Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, particularly in the areas of toileting assistance and timely response to call lights. Multiple observations documented residents waiting extended periods for assistance, including one resident with a history of hip fracture and impaired mobility who was left sitting on the toilet for half an hour with her catheter bag improperly positioned, and another resident who waited in a soiled brief for staff to assist with changing. Call lights were observed to be activated for prolonged periods without response, and residents and their roommates reported repeatedly calling for help without timely staff intervention. Interviews with residents revealed consistent concerns about delayed responses to call lights, with some reporting waits of up to two hours for assistance with transfers and personal care. Residents described staff placing multiple briefs on them to reduce the frequency of changes, which caused discomfort. Staff interviews confirmed that staffing levels were inadequate, with frequent reliance on agency staff and management personnel filling in for direct care roles. Staff reported being called to work extra hours and noted that most residents required assistance from two staff members, especially for transfers involving mechanical lifts. Review of facility records, including call light response reports, resident council meeting notes, and the facility assessment, corroborated the observations and interviews. Call light response times frequently exceeded the facility's 15-minute expectation, with some instances documented at over an hour. Resident council notes and grievance logs indicated ongoing concerns about call light response times, with multiple residents expressing dissatisfaction over several months. The facility assessment acknowledged the high acuity and dependency of the resident population, but staffing plans and actual staffing levels did not consistently ensure timely care and response to resident needs.
Failure to Maintain Adequate Supplies, Cleanliness, and Pest Control
Penalty
Summary
Facility leadership failed to provide adequate management, resulting in insufficient incontinent and linen supplies, unclean resident environments, and a kitchen infested with vermin. Observations revealed black substances on air conditioner vents, missing wall bases, stained and unmade beds, foul odors, and minimal supplies in utility rooms. Staff interviews confirmed frequent shortages of gloves, wipes, and briefs, with staff resorting to makeshift solutions such as using washcloths or tying pull-ups to fit residents. Residents and staff reported running out of clean linens regularly, and soiled linens with deep stains were observed, some of which could not be cleaned and had to be discarded. Multiple staff and residents reported ongoing pest infestations, including mice, ants, cockroaches, and flies, particularly in the kitchen and resident rooms. The kitchen was described as extremely dirty, with years of accumulated grime, frequent flooding, and evidence of rodent nests and droppings. Staff reported that management was repeatedly informed of these issues, but little to no action was taken. The kitchen also suffered from structural issues such as leaking ceilings and standing water, and cleaning documentation was lacking or unavailable. Housekeeping and maintenance concerns extended to other facility areas, with reports of leaking ceilings, water-stained walls, and mice droppings found on laundry. Staff and residents noted that rooms were not cleaned frequently enough, and pest issues were downplayed by management. Leadership, including the Acting Administrator and Regional Director of Operations, were often unaware of the extent of the problems, citing lack of staff reporting and infrequent presence in affected areas. The facility's failure to maintain a clean, safe, and adequately supplied environment was corroborated by resident council meeting notes and multiple staff and resident interviews.
Failure to Address Repeated Quality Deficiencies in QAPI Process
Penalty
Summary
The facility failed to ensure an effective process for addressing previously identified quality deficiencies, as evidenced by repeated citations for infection control and maintaining a safe, clean, and homelike environment in both 2023 and 2024. Despite the facility's QAPI plan outlining a monitoring process using multiple data sources, it did not specify a method for addressing recurring deficiencies. Review of QAPI meeting minutes since November 2024 revealed that the same issues were repeatedly discussed without documented follow-through or resolution. During interviews, the DON, who serves as the acting QAPI designee, was unable to explain the lack of follow-through or documentation regarding these repeated issues, and the RDO acknowledged that previous leadership had not implemented the QAPI plan as intended.
Failure to Follow Infection Control Practices During Resident Care and Transfers
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices during direct observation, record review, and staff interviews. Staff were observed transferring a resident with an indwelling catheter using a mechanical lift sling taken from another resident's room without sanitizing it, and without utilizing Enhanced Barrier Precautions (EBP) as required for residents with indwelling medical devices. Staff interviews confirmed that EBP should have been used during such high-contact activities, and that each resident should have their own clean sling or a properly sanitized one if shared. In another instance, staff provided incontinence care to a resident with chronic conditions including a left above-knee amputation and moisture-associated skin disorder. During care, staff failed to consistently change gloves and sanitize hands between tasks, and handled clean supplies and equipment with contaminated gloves. Soiled linens were placed on top of a trashcan in the resident's room, and the mechanical lift was wheeled to a common area after use, raising concerns about environmental contamination. Additionally, staff were observed providing pericare to a resident with dementia and incontinence without changing gloves or sanitizing hands between dirty and clean tasks. Interviews with the Infection Preventionist, Director of Nursing, and other nursing staff confirmed that facility policy requires glove changes and hand hygiene between tasks and after glove removal, as well as disinfection of equipment between residents. These lapses were inconsistent with the facility's own infection control policies and standard precautions.
Failure to Lock Bed Brakes and Improper Mechanical Lift Use During Resident Transfers
Penalty
Summary
Staff failed to lock the brakes on a resident's bed while providing incontinence care and repositioning, resulting in the bed moving during the process. The resident, who had a history of left above-the-knee amputation, fracture, muscle weakness, morbid obesity, and anxiety disorder, was dependent on staff for transfers and had a documented risk for falls. During the observed care, the resident expressed concern about falling, and the Regional Nurse present confirmed that the bed brakes were not engaged and that the resident was positioned close to the edge of the bed. Additionally, staff did not operate a mechanical lift according to manufacturer instructions during transfers for two residents. In one instance, the sling strap was looped around the armrest of a wheelchair, requiring adjustment while the resident was suspended in the lift. The mechanical lift's leg bar was not spread as recommended by the manufacturer during the transfer, and the lift encountered obstacles under the bed. The staff involved did not demonstrate competency in the safe use of the mechanical lift, and the facility's policy lacked specific guidance on the correct positioning of the lift's leg bar during transfers. Interviews with facility leadership confirmed that staff were expected to follow manufacturer instructions for mechanical lifts, but there had been no recent competency audits or survey preparation related to transfers. The facility's observation form for lift/transfer safety did not include detailed steps for using mechanical lifts, and the relevant policies did not address the specific issues observed during the transfers.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving three residents. One resident reported experiencing pain after pericare was performed by a CNA, who was described as rough. Despite the resident's complaint, the CNA continued to work without immediate suspension or investigation. The resident's care plan noted a history of false allegations, but the facility did not take immediate action to ensure the resident's safety or investigate the claim thoroughly. Another incident involved a CNA reportedly using excessive force while repositioning a resident and making threatening statements. The CNA continued to work with residents until the incident was reported to the DON two days later. The resident involved had communication deficits, making it difficult to ascertain the full extent of the incident. The facility's delayed response and failure to immediately suspend the CNA placed residents at risk. The facility's investigation into these incidents was inadequate, as staff continued to work without proper oversight or immediate action. The facility's policies on abuse and neglect were not effectively implemented, leading to a situation where residents were not adequately protected from potential harm. The lack of timely reporting and investigation of abuse allegations contributed to the deficiency.
Removal Plan
- All facility staff education provided on Abuse and Neglect Standards and Reporting.
- The facility will continue to educate facility staff on Abuse and Neglect upon hire, as needed, and increase education associated with abuse scenario training monthly.
- Residents were interviewed related to abuse concerns.
- All active employee files were reviewed for mandatory abuse education and disciplinary actions associated with allegations or potential abuse/neglect.
Cluttered Hallways and Lack of Policies Lead to Unsafe Environment
Penalty
Summary
The facility failed to ensure a homelike environment and reduce clutter in the hallways of both the North and South Halls, which led to several incidents involving residents and staff. Observations revealed that equipment such as mechanical lifts, shower chairs, PPE bins, trash and soiled laundry carts, medication carts, treatment carts, and wheelchairs were parked along the hallways and handrails, obstructing passage. On multiple occasions, residents in wheelchairs were unable to pass each other due to the clutter, resulting in arguments and the need for staff intervention. Additionally, a surveyor tripped over an open mechanical lift leg in the South Hall, further highlighting the safety hazards posed by the cluttered environment. The facility lacked specific policies for equipment storage and transporting residents in wheelchairs, as confirmed by interviews with the Regional Corporate Nurse Consultant and the Regional Director of Operations. The Homelike Environment policy, revised in February 2021, stated that residents should be provided with a safe, clean, comfortable, and homelike environment, which was not upheld in this case. The absence of a policy for equipment storage and the improper use of wheelchairs without foot pedals contributed to the unsafe and cluttered conditions observed in the facility.
Sanitation and Food Safety Deficiencies in Facility
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and service, as observed during a survey. Staff C was seen serving dinner without washing her hands after licking her finger and touching her lips. Additionally, Staff D and Staff E were observed with improper hair net usage, allowing hair to hang outside the net. The kitchen inspection revealed several unsanitary conditions, including dried leaves and dirt on the floor, stained ceiling tiles, and unlabeled and undated food items in refrigerators and freezers. The facility's policies on food storage, preparation, and hygiene were not adhered to, as evidenced by the lack of proper labeling, dating, and storage of food items. Further observations showed that the dietary staff did not follow proper hygiene practices. Staff X and Staff T, both CNAs, were seen serving meals with their thumbs inside pudding bowls, and Staff X and Staff L handled dinner rolls with bare hands, applying butter and jelly without gloves. The facility's policies require gloves to be worn when handling ready-to-eat food and for gloves to be changed between tasks, which was not followed. The dietician and DON confirmed that staff should not have direct contact with residents' food without proper sanitation measures. The facility's equipment and storage areas were also found to be in poor condition. A refrigerator thermometer was broken, and the temperature was above the safe level for food storage. Unlabeled and undated food items, such as diced chicken and barbeque sauce, were found in the refrigerators and freezers. A container of strawberries in syrup was found to be spoiled, with visible mold and a foul smell, indicating it had been stored far beyond the recommended time. These findings highlight a significant lapse in maintaining food safety and hygiene standards as per the facility's policies.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure timely reporting of abuse allegations involving three residents, leading to an Immediate Jeopardy situation. For one resident, an incident occurred where the resident reported feeling pain during pericare, alleging rough treatment by a CNA. Despite the resident's initial complaint, the nurse's assessment found no physical signs of abuse, and the resident later denied any pain. However, the incident was not reported to the Department of Inspections, Appeals, and Licensing (DIAL) until several weeks later, indicating a delay in the reporting process. Another incident involved a resident with cognitive impairments who was allegedly handled roughly by a CNA during a transfer. The CNA reportedly made threatening remarks to the resident, which were overheard by another staff member. This staff member did not report the incident immediately, leading to a delay in addressing the potential abuse. The resident later confirmed feeling rough handling but denied feeling unsafe. The delay in reporting this incident to the appropriate authorities further contributed to the Immediate Jeopardy finding. The facility's policies required immediate reporting of abuse allegations, but staff failed to adhere to these protocols. The incidents were not reported within the required timeframes, and staff involved continued to work with residents, potentially placing them at risk. The facility's failure to protect residents from abuse and ensure timely reporting of allegations resulted in a serious deficiency, necessitating immediate corrective actions.
Removal Plan
- All facility staff education on Abuse and Neglect Standards and Reporting initiated. Facility will continue to educate facility staff on Abuse and Neglect upon hire, as needed, and increase education associated with abuse scenario training monthly.
- Residents were interviewed related to abuse concerns.
- All active employee files were reviewed for mandatory abuse education and disciplinary actions associated with allegations or potential abuse/neglect.
- Progress notes, grievances, and critical events reviewed routinely by facility staff to identify potential abuse, neglect, and exploitation opportunities, and act upon these immediately. The facility implemented an event tracking log to review these items routinely, and allow key staff to view approaching timelines, and trend and track the events.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner, as evidenced by multiple instances of extended response times documented in resident council minutes, staff disciplinary records, and resident interviews. The resident council meetings consistently highlighted concerns about call light response times, with residents noting improvements but still expressing dissatisfaction. Staff disciplinary records for CNAs revealed repeated instances of call lights being left unanswered for over 20 minutes, with some response times extending to over an hour. Resident interviews corroborated these findings, with several residents reporting delays in receiving assistance, particularly during weekends and night shifts. The facility's policy on call light response, revised in September 2022, emphasized the importance of timely responses, yet the facility's staffing levels appeared insufficient to meet this standard consistently. The facility assessment indicated an effort to maintain adequate staffing, but the documented response times suggest that these efforts were not always successful. The Regional Director of Operations acknowledged the issue, noting that call light response times were part of the facility's Quality Assurance Performance Improvement process. Despite some improvements in response times since March 2024, the facility continued to experience significant delays, particularly during evening and night shifts. The Director of Nursing stated that the expectation was for call lights to be answered within 15 minutes, but this standard was not consistently met, as evidenced by the documented response times and resident feedback.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required Medicare Liability Notices and Beneficiary Appeals forms to three sampled residents within the mandated 48-hour window after the end of skilled services. For Resident #26, the Notice of Medicare Non-Coverage (NOMNC) was issued and signed within the required timeframe, but the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was missing. Similarly, for Resident #204, the NOMNC was signed by the power of attorney within the required window, but the SNFABN was not provided. Resident #205 received both the NOMNC and SNFABN within the required timeframe, but the SNFABN lacked the necessary disclosure of the cost of services if the resident chose to pay out of pocket. Interviews with the Regional Director of Operations and the President of Clinical Reimbursement revealed uncertainty as to why SNFABNs were not issued for Residents #26 and #204. The President of Clinical Reimbursement confirmed that Resident #205's SNFABN should have included the cost of services. The facility's policy states that SNFABNs are to be provided if the beneficiary intends to continue services and the Skilled Nursing Facility believes the services may not be covered under Medicare.
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment tool for one resident, leading to a discrepancy in the documentation of the resident's discharge destination. The MDS assessment for the resident indicated that he was discharged to a short-term general hospital, while other documentation, including the Discharge Plan and Notice of Transfer Form, indicated that the resident was discharged to a waiver-based housing with home health. This inconsistency was identified during a review of the resident's records. Interviews with facility staff revealed that the President of Clinical Services, who signs off on MDS assessments, was unaware of the reason for the incorrect documentation and speculated that the Social Worker might have selected the wrong option. The Social Worker acknowledged the error, stating that the resident was not discharged to the hospital and suggested that the mistake might have occurred because the resident was initially admitted from a hospital. The Social Worker admitted that the discharge to a community setting should have been documented on the MDS.
Failure to Update PASRR Screening for Resident with Significant Change
Penalty
Summary
The facility failed to submit a new preadmission screening and resident review (PASRR) level 1 screening for a resident who experienced a significant change in condition. The resident, identified as having moderate cognitive impairment, had a history of stroke, non-Alzheimer's dementia, hemiparesis, seizure disorder, depression, and psychotic disorder. The resident's care plan, revised in November 2024, documented a delusional disorder and the use of antipsychotic and antidepressant therapy. The medication administration record for November 2024 showed daily use of Olanzapine and Venlafaxine. The original PASRR level 1 screening from August 2022 did not document the resident's delusional or psychotic disorder, nor did it document depression or a seizure disorder, despite the resident's current treatment with Olanzapine. The facility's policy required a new PASRR screening if there was a significant change in treatment needs. The regional nurse consultant confirmed that the facility did not have an updated PASRR, and the social worker acknowledged that the change in treatment and diagnosis required a resubmission, which was overlooked during the resident's reevaluation.
Inadequate Behavioral Documentation for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to adequately track and document behaviors for residents taking psychiatric medications, as evidenced by discrepancies in the records of three residents. Resident #32, with moderate cognitive impairment and multiple diagnoses including stroke and psychotic disorder, was on antipsychotic and antidepressant therapy. The care plan directed staff to use non-drug approaches but did not specify the behaviors or interventions. The Medication Administration Record (MAR) and nursing progress notes documented behaviors on various dates, yet the electronic health record (EHR) showed no behaviors, indicating a lack of consistent documentation. Resident #11, also with moderate cognitive impairment and psychiatric diagnoses, was receiving psychotropic medication. The care plan mentioned non-drug approaches but lacked specifics. The MAR included medications for psychiatric conditions but did not document non-pharmacological interventions for behavioral issues. Nursing progress notes and the EHR lacked consistent documentation of behaviors, with only one entry in the EHR noting no behaviors observed. Resident #24, with intact cognition and psychiatric diagnoses, was on psychotropic medication therapy. The care plan noted manipulative behavior but did not specify non-drug interventions. The MAR documented anxious behaviors on one day, while nursing progress notes recorded behaviors on multiple days, with specific behaviors noted only once. The EHR contained no documentation of behaviors, showing a discrepancy with the nursing progress notes. Interviews with staff revealed a lack of awareness and understanding of behavior monitoring responsibilities, contributing to the deficiency.
Failure to Administer Insulin Correctly
Penalty
Summary
The facility failed to administer insulin correctly to a resident with Diabetes Mellitus, leading to a significant medication error. During a medication pass, an LPN was observed administering insulin Lispro using a pen-injector without performing necessary steps such as priming the pen and purging two units of insulin to ensure it was functioning properly. The LPN also did not hold the pen to the resident's skin for the recommended duration to ensure complete administration of the medication. Additionally, the LPN did not perform hand hygiene before preparing the medication, which is a critical step in preventing contamination and ensuring patient safety. Interviews with the Regional Corporate Nurse Consultant and the Director of Nursing revealed that the LPN did not follow the manufacturer's instructions for the insulin pen, which included priming the pen and holding it to the skin for at least five seconds. The Director of Nursing stated that the expectation is for staff to follow these guidelines, and the Licensed Pharmacist confirmed that failure to perform these steps could result in the resident not receiving the full dose of medication. The manufacturer's insert for the Lispro pen injector also outlined these steps as necessary for safe and effective usage.
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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