Azria Health Winterset
Inspection history, citations, penalties and survey trends for this long-term care facility in Winterset, Iowa.
- Location
- 1015 West Summit, Winterset, Iowa 50273
- CMS Provider Number
- 165188
- Inspections on file
- 22
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Azria Health Winterset during CMS and state inspections, most recent first.
The facility failed to maintain proper infection control practices, with staff neglecting hand hygiene during resident interactions and medication administration. Shower equipment was not adequately sanitized between uses, and inappropriate cleaning agents were used. Additionally, the facility did not conduct sufficient influenza testing during a respiratory infection outbreak, despite available tests and CDC recommendations.
The facility failed to maintain a homelike environment, as several residents' rooms had unrepaired damages such as chipped drywall and missing paint. Observations and interviews revealed that maintenance issues were reported but not consistently addressed, with the Maintenance Director acknowledging delays in repairs. The lack of a systematic approach to maintenance led to unresolved environmental deficiencies, contrary to the facility's policy.
The facility failed to supervise medication administration, allowing residents to self-administer medications without proper oversight. An LPN left medications unattended for residents with varying cognitive abilities, and a resident applied medicated cream without a physician's order for self-administration. The DON confirmed the lack of assessments and policy adherence for self-administration.
The facility failed to secure shower rooms containing hazardous materials, allowing residents with severe cognitive impairments to access these areas unsupervised. Additionally, a resident with Huntington's Disease was observed being pushed in a wheelchair without foot pedals, contrary to facility policy, posing a risk of injury. Staff interviews confirmed these practices, and the DON was unaware of the door latching issue.
The facility failed to store food properly and maintain hand hygiene standards. Open food items were undated, and sanitization checks for the dish machine were inadequate. Staff did not perform hand hygiene between tasks, as observed with a cook and a CMA assisting residents. Interviews confirmed the expected protocol was not followed, highlighting deficiencies in maintaining a sanitary environment.
A facility failed to provide a resident with the required Notice of Medicaid Non-Coverage (NOMNC) when initiating a discharge before the resident had exhausted their Medicare Part A benefit days. Although an Advanced Beneficiary Notification (ABN) was present, the NOMNC was missing due to the absence of the responsible staff member. The facility's policy required written notification of coverage changes, which was not followed.
A resident with severe cognitive impairment was not accurately assessed for the use of a wander guard in the MDS, despite documentation and observations indicating its use. The facility's EHR and MAR noted the need to check the wander guard each shift, and the care plan identified a risk for wandering. The MDS Coordinator and DON acknowledged the coding error, which did not align with the facility's assessment policy.
A resident with severe cognitive impairment and a history of stroke did not receive proper contracture management as per physician's orders. Observations showed the absence of a required splint and carrot on the resident's left hand. Staff interviews confirmed the splint was not applied due to being lost, and the care plan needed updating to reflect the correct use of devices.
The facility failed to assist two residents with personal grooming. One resident with severe cognitive impairment was observed with unshaved facial hair, despite a care plan requiring staff assistance. Another resident was seen with crusted eyelids, although records showed hygiene tasks were marked as completed or not applicable. The DON confirmed staff were expected to provide necessary grooming assistance.
A resident with an enteral feeding tube received formula administered by an LPN using a piston syringe, contrary to facility policy requiring gravity flow. The LPN was unaware of the correct procedure, and the DON confirmed the residual check was performed incorrectly, highlighting a deviation from established protocols.
A facility failed to document non-pharmacological interventions before administering PRN anti-anxiety medication to a resident with severe cognitive impairment. Despite care plan directives and facility policy, the MARs showed multiple instances of Ativan administration without prior non-pharmacological attempts, as confirmed by the DON. The facility lacked a specific policy for PRN medication administration.
A resident with type 2 diabetes received an incorrect dose of Humalog Lispro insulin due to a staff member's failure to prime the insulin pen as required. The facility's policy did not include procedures for insulin pen use, leading to a significant medication error.
A resident with moderate cognitive impairment was administered Oxycodone 5 mg every 4 hours for pain, but the medication label indicated it was to be given as needed. The discrepancy between the label and the physician's order was not noticed by the LPN during administration. The DON acknowledged the error, noting that the pharmacy sent the wrong order and the nurse failed to clarify the discrepancy. The facility's policy on verifying medication details before administration was not followed.
A resident with cerebral palsy and muscle weakness fell from bed due to improper use of a mechanical lift by a single CNA, contrary to facility policy requiring two staff members. The CNA encountered resistance while moving the lift, leading to the resident's fall and a forehead bruise. Staff interviews revealed a lack of awareness and competency assessment for the CNA regarding mechanical lift use.
The facility failed to ensure the Dietary Manager met the qualifications of a Certified Dietary Manager (CDM) in the absence of a full-time dietitian. The Dietary Manager, previously a CNA and Dietary Aide, had not completed the necessary certification course. Although she completed ServSafe training, she was not yet a CDM as required by the facility's job description. She was enrolled in a certification course at the time of the survey.
The facility was found to have improper food storage practices, including expired tomato juice, uncovered glasses of juice, and undated food items stored incorrectly. The Dietary Manager and Registered Dietitian had specific expectations for food storage that were not met, and the facility's policy requires all refrigerated or frozen foods to be covered, labeled, and dated.
A resident with bipolar disorder and non-Alzheimer's dementia, who valued taking care of personal belongings, frequently reported missing laundry items. Despite a history of trust issues and previous reports of missing laundry, the care plan was not updated to include these concerns or effective interventions, contrary to the facility's policy on person-centered care plans.
A resident at high risk for pressure ulcers did not receive consistent application of protective boots as ordered by the physician. Despite care plan directives and facility policy, observations showed the resident often without bunny boots, leading to a deficiency in care.
A resident with Alzheimer's and other conditions was not consistently provided with finger foods as per their care plan, leading to significant weight fluctuations. Despite being on hospice care and having a preference for finger foods, observations showed meals were not aligned with dietary needs, and staff did not assist during meals. Interviews revealed inconsistencies in understanding and implementing the resident's dietary requirements.
The facility did not post required notifications about survey agencies and advocacy support, nor did it provide access to updated survey results. Observations during a survey revealed missing information on contacting state agencies and outdated survey results since 2021. The Administrator confirmed the absence of updated postings and survey results, leading to a deficiency in meeting residents' rights.
Inadequate Infection Control and Testing Practices
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by multiple observations of staff neglecting hand hygiene protocols. Staff members, including a Certified Nursing Assistant (CNA) and Licensed Practical Nurses (LPNs), were observed not performing hand hygiene before and after resident contact, during medication administration, and after glove removal. This lack of adherence to hand hygiene protocols was noted during interactions with residents, including those with wounds and those receiving medications, potentially increasing the risk of infection transmission. Additionally, the facility did not ensure proper sanitization of shower equipment between resident uses. A CNA was observed using a shower chair with a visible brown stain without sanitizing it before assisting a resident. The CNA used a diluted Clorox solution, prepared without precise measurement, to clean the chair, and did so without wearing gloves. The Housekeeping Manager confirmed that Clorox was used instead of a healthcare-grade disinfectant, and the dilution process lacked documentation and standardization. The facility also failed to conduct adequate influenza testing during a period of increased respiratory infections. Despite having influenza tests available, the facility only tested for influenza after a resident tested positive, relying primarily on COVID-19 testing. The Infection Preventionist was unaware of a regional influenza outbreak and had not maintained regular communication with public health authorities. This oversight in testing practices did not align with CDC recommendations for testing residents with respiratory symptoms for both SARS-CoV-2 and influenza.
Failure to Maintain Homelike Environment Due to Unrepaired Damages
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple instances of unrepaired damages in resident rooms. Observations revealed chipped drywall, missing paint, and exposed sharp edges in the rooms of several residents. For instance, Resident #31's room had chipped drywall and missing paint behind the bed and under the window. Resident #33's room had a quarter-sized area of missing paint with deep grooves behind the chair. Resident #43's room had missing paint near the bathroom and above the light fixture, which the resident found bothersome. Resident #47, who had recently moved into the facility, noted large areas of different colored paint and chipped paint in her room, which had not been addressed before her admission. Staff interviews indicated that maintenance issues were reported through 'fix it tickets,' but the Maintenance Director did not receive many of these tickets and did not document repairs or touch-ups. The Maintenance Director acknowledged the need for regular touch-ups but admitted that repairs were often delayed, with some areas only being painted over without proper repair. The Administrator stated that environmental concerns should be reported via fix it tickets, but there was no formal procedure for checking rooms for repairs. Despite the policy requiring the maintenance department to maintain the facility in a safe and operable manner, the lack of a systematic approach to addressing and documenting maintenance issues led to unresolved environmental deficiencies. This failure to provide a homelike environment was evident in the observations and resident interviews, highlighting a gap in the facility's maintenance processes.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards by allowing residents to self-administer medications without proper supervision. Resident #8, with no cognitive impairment, was observed self-administering medications outside the view of the LPN, who had left the room to retrieve a glucose machine. Similarly, Resident #31, also with no cognitive impairment, had a medication cream left unattended in their room, which the LPN later denied leaving. Resident #33, with mild cognitive impairment, was left alone with medications on the bedside table while the LPN attended to another staff member's request, resulting in the resident self-administering the medications unsupervised. Resident #41, with intact cognition but diagnosed with non-Alzheimer's dementia, was observed applying a medicated cream to his trunk without a physician's order for self-administration. The DON confirmed that none of the residents had been assessed or authorized for self-administration of medications, and the facility lacked a policy for such assessments. The facility's policy required that medications be administered safely and timely, with residents only self-administering if deemed capable by a physician and care planning team, which was not adhered to in these cases.
Failure to Secure Hazardous Areas and Ensure Safe Mobility
Penalty
Summary
The facility failed to protect residents from hazards, accidents, and injuries by not securing two shower rooms that contained chemicals, sharp razors, and biohazard containers. Observations revealed that the shower room doors were often left open and unattended, allowing residents with severe cognitive impairments, such as those with Alzheimer's disease, to access these hazardous areas. Staff interviews confirmed that the doors were not consistently shut, and the cabinets containing dangerous items were not locked. The Director of Nursing (DON) was unaware of the issue with the door not latching properly and had not been informed by staff about residents entering the shower rooms unsupervised. Resident #43, who had a severe cognitive impairment and a history of wandering, was observed near the shower room, which was across the hall from her room. Staff acknowledged that Resident #43 would sometimes enter the shower room unattended, searching for personal items like hair rollers. Despite the presence of a wander guard, the resident was able to access the shower room, which posed a significant risk due to the unsecured hazardous materials inside. The DON had a conversation with staff about keeping the door closed but did not document any formal corrective actions. Additionally, Resident #39, who had severe cognitive impairment and Huntington's Disease, was observed being pushed in a wheelchair without foot pedals, causing his feet to drag on the ground. This practice was against facility policy, as it posed a risk of injury to the resident. Staff interviews confirmed that they were instructed not to push residents without foot pedals, yet this practice was observed multiple times. The DON stated that the expectation was for staff to use foot pedals to avoid injury, but this was not consistently followed, leading to potential harm for Resident #39.
Deficiencies in Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage and sanitization, as observed during a survey. In the kitchen, open food items such as orange juice, apple juice, and cranberry cocktail were found undated in the refrigerator, and chicken cordon bleu and hamburgers were left open to the air in the freezer. Staff A, the Certified Dietary Manager, acknowledged these items should have been properly sealed and dated. Additionally, the facility did not conduct appropriate chemical sanitization checks for the low-temperature dish machine, as test strips showed no color change, indicating a lack of chlorine. Staff A admitted that the dish machine was supposed to be checked daily, but the facility did not keep track of the chemical strip test results. Further observations revealed lapses in hand hygiene practices among staff. Staff B, a cook, was seen handling food and touching various surfaces without performing hand hygiene. This included using a slotted spoon on a soiled surface and then using it again without cleaning it. Similarly, during dining room service, Staff V, a Certified Medication Aide, assisted two residents with eating without sanitizing her hands between tasks or after touching her face. Interviews with other staff members, including CNAs and the Director of Nursing, confirmed that the expected protocol was to sanitize hands before assisting residents and after touching anything outside the dining table. The facility's policies on sanitization and food storage were not followed, as evidenced by the lack of proper labeling and dating of food items and inadequate sanitization practices. The Certified Dietary Manager and other staff members acknowledged the need for more rigorous hand hygiene and sanitization measures during food preparation and resident assistance. The facility's failure to adhere to these standards was confirmed through staff interviews and policy reviews, highlighting deficiencies in maintaining a safe and sanitary environment for residents.
Failure to Provide Required Notice of Medicaid Non-Coverage
Penalty
Summary
The facility failed to provide a resident with the required Notice of Medicaid Non-Coverage (NOMNC) when initiating a discharge before the resident had exhausted their Medicare Part A benefit days. The clinical records indicated that the resident's Medicare Part A coverage began upon entering the facility and that the resident was discharged from skilled services without receiving the NOMNC. Although an Advanced Beneficiary Notification (ABN) was present in the file, the NOMNC was missing. The facility administrator confirmed that the staff member responsible for providing the notice was not available at the time it was required, resulting in the omission. The facility's policy stated that residents should be notified in writing of changes in coverage as soon as possible, but this was not adhered to in this instance.
Inaccurate MDS Documentation of Wander Guard Use
Penalty
Summary
The facility failed to accurately assess and document the use of a wander guard for a resident with severe cognitive impairment. The Quarterly Minimum Data Set (MDS) for the resident did not reflect the use of a wander guard, despite observations and documentation indicating its presence on the resident's walker. The resident, who had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, was observed ambulating with an unsteady gait and attempting to exit the facility, necessitating redirection by staff. The facility's Electronic Health Records (EHR) and Medication Administration Record (MAR) documented an order to check the placement and function of the wander guard each shift, and the resident's care plan identified a risk for wandering/elopement. However, the MDS section P, which should have documented the use of wander/elopement alarms, was inaccurately coded. Both the MDS Coordinator and the Director of Nursing (DON) acknowledged the error, which was contrary to the facility's policy on comprehensive assessments that require accurate representation of a resident's clinical status.
Failure to Implement Comprehensive Care Plan for Resident with Contracture
Penalty
Summary
The facility failed to provide a comprehensive care plan for a resident with severe cognitive impairment and a history of stroke, osteoporosis, and muscle weakness. The resident required staff assistance with most Activities of Daily Living (ADLs) and had a physician's order for a left hand splint to be applied each morning and removed after lunch. However, observations on two separate occasions revealed that the resident's left hand contracture was not being managed as ordered, with neither a brace nor a carrot present on the left hand. Interviews with staff, including a Restorative Aide and the Director of Nursing (DON), confirmed that the resident typically wore a splint for contracture prevention, but it was not applied due to being possibly lost in the laundry. The DON acknowledged that the care plan and Minimum Data Set (MDS) needed updating to accurately reflect the use of both the brace and carrot for contracture prevention. The therapist involved was a new graduate and did not specify that the carrot and brace were two different devices to be applied to the resident's left hand.
Failure to Assist Residents with Personal Grooming
Penalty
Summary
The facility failed to assist two residents with their activities of daily living, specifically in the area of personal grooming. Resident #11, who has severe cognitive impairment due to a stroke and other health conditions, was observed with long, unshaved facial hair on multiple occasions. Despite the care plan indicating the need for staff assistance with personal hygiene, the grooming task was not completed as expected. The Director of Nursing confirmed that staff were aware of the resident's needs and that the expectation was for grooming to be carried out during bathing. Similarly, Resident #26, who also depends on staff for personal hygiene, was observed with dried crust around both eyelids on two separate occasions. The clinical records indicated that personal hygiene tasks were either marked as completed or not applicable without explanation. However, subsequent observations showed no concerns with grooming. The Director of Nursing reiterated the expectation for staff to provide necessary hygiene and grooming assistance to residents requiring help.
Improper Administration of Enteral Feeding
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding the administration of enteral feeding for a resident. The resident, who was rarely or never understood and utilized an enteral feeding tube, was observed receiving enteral formula administered by a Licensed Practical Nurse (LPN) using a piston syringe. The LPN poured the formula into the syringe and manually pushed the piston to administer the feeding, contrary to the facility's policy which required the feeding to flow by gravity. The LPN admitted to not knowing if it was acceptable to push the formula, indicating a lack of proper training or understanding of the facility's procedures. Additionally, the Director of Nursing (DON) confirmed that the residual check, which is necessary to ensure the resident had digested the previous formula and to prevent dumping, was performed incorrectly after the feeding instead of before. The DON acknowledged that the resident received bolus feedings and disagreed with the method of pushing the formula, emphasizing the need for gravity flow. The facility's policy, revised in November 2018, clearly stated that the feeding should be allowed to flow by gravity, highlighting a deviation from established protocols in the care of the resident.
Failure to Document Non-Pharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to ensure that staff documented non-pharmacological interventions before administering as-needed (PRN) anti-anxiety medication to a resident with severe cognitive impairment. The resident, diagnosed with non-Alzheimer's dementia, anxiety disorder, and depression, had a Brief Interview for Mental Status (BIMS) score of 1 out of 15, indicating severely impaired cognition. The facility's policy required medications to be administered according to prescriber orders, and the resident's care plan directed staff to attempt non-pharmacological approaches to manage behaviors. However, the Medication Administration Records (MARs) for January, February, and March 2025 showed multiple instances where the resident received Ativan without documentation of attempted non-pharmacological interventions. The Director of Nursing confirmed that staff should document non-pharmacological interventions before administering PRN anti-anxiety medications, but the facility lacked a specific policy for PRN medication administration. The resident's care plan entries from 2017 and 2024 indicated the use of non-pharmacological approaches and anti-anxiety medications, respectively. Despite these directives, the MARs and progress notes lacked evidence of non-pharmacological interventions being attempted prior to administering the medication, leading to the deficiency identified during the survey.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The incident involved a resident with a diagnosis of type 2 diabetes, who had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. During an observation, a staff member administered Humalog Lispro insulin to the resident without priming the insulin pen with 2 units as required. The resident's blood glucose level was 108, and the staff member drew up 4 units of insulin without priming the pen, which is against the manufacturer's instructions. The insulin was administered to the resident's right thigh, and the pen was returned to the medication cart without proper priming. The facility's policy on insulin administration, revised in September 2014, stated that nursing staff should have access to specific instructions on all forms of insulin delivery systems. However, the policy provided by the facility only included procedures for insulin injections via syringe, not for insulin pens. The Director of Nursing (DON) confirmed that the insulin pen should have been primed with 2 units before dialing the dose to be administered. The failure to follow the correct procedure for insulin administration led to the potential for the resident to receive an incorrect dose of insulin.
Medication Labeling Discrepancy for Resident
Penalty
Summary
The facility failed to ensure that medications were labeled in accordance with currently accepted professional principles, resulting in a discrepancy between the medication label and the physician's order for a resident. The resident, who had moderate cognitive impairment and a diagnosis of unspecified pain, was prescribed Oxycodone 5 mg to be administered every 4 hours for pain. However, the medication bubble pack label indicated that the Oxycodone was to be administered as needed for post-operative and chronic back pain. This discrepancy was observed when a Licensed Practical Nurse (LPN) administered the medication to the resident without noticing the mismatch between the label and the Medication Administration Record (MAR). The Director of Nursing (DON) acknowledged the discrepancy and stated that the medication label should have matched the order. The DON explained that the resident had returned from the hospital with both as-needed and routine orders for Oxycodone, but the as-needed order was supposed to be discontinued. The pharmacy sent the wrong order, and the nurse did not clarify the discrepancy after receiving the medication. The facility's policy required staff to verify the right resident, medication, dosage, time, and route before administering medications, but this was not followed, leading to the deficiency.
Failure to Ensure Proper Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure the presence of two staff members during the use of a mechanical lift for resident transfers, which is a requirement according to the facility's policy. This deficiency was identified during a review of an incident involving a resident with cerebral palsy, deep vein thrombosis, and muscle weakness, who required extensive assistance for bed mobility and total dependence on two staff for transfers. The resident experienced a fall from the bed due to improper handling of the mechanical lift by a single Certified Nursing Assistant (CNA), Staff M, who attempted to transfer the resident alone. During the incident, Staff M used a Hoyer lift to transfer the resident from a wheelchair to the bed. After placing the resident in bed, Staff M attempted to pull the lift away, encountering resistance. Believing the resistance was due to the lift's wheels, Staff M continued to tug on the lift, inadvertently causing the resident to fall to the floor. It was later discovered that one of the sling straps was still attached to the lift, which led to the fall. The resident sustained a bruise on the forehead as a result of the fall. Interviews with staff revealed that Staff M was not aware of the requirement for two staff members during mechanical lift transfers and had not completed a competency assessment for the use of such equipment. The Director of Nursing (DON) and other staff members confirmed that there was no orientation checklist or competency sign-off for Staff M regarding the mechanical lift. The facility's policy clearly states that at least two nursing assistants are needed to safely move a resident with a mechanical lift, and this policy was not adhered to during the incident.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the dietary service manager met the required qualifications of a Certified Dietary Manager (CDM) in the absence of a full-time dietitian. During an initial kitchen walkthrough, the Dietary Manager, identified as Staff F, admitted to not having taken the course to become a certified dietary manager. Her prior experience included working as a Certified Nurse Aide (CNA) and a Dietary Aide. Although the facility provided a certificate showing that Staff F completed ServSafe training, it was noted that she was not yet certified as a dietary manager. The facility's job description for the Dietary Manager position, revised in February 2021, required that the individual be a CDM within one year of employment. At the time of the survey, Staff F was enrolled in an Iowa Food Manager Certification Course, which she was expected to complete soon.
Improper Food Storage Practices
Penalty
Summary
The facility failed to maintain sanitary food storage practices as observed during a survey. A pitcher of tomato juice was found in a refrigerator with a used by date that had already passed. Additionally, a soiled tub containing two uncovered glasses of juice was observed on a refrigerator shelf. In the walk-in cooler, a pound cake was seen in an undated, zippered food storage bag placed on top of a package of turkey lunch meat. In the dry storage room, a bag of pasta and a bag of brownie mix were found open to the air without any open dates. The Dietary Manager stated that juice glasses should be covered and stored in a clean bin, while the Registered Dietitian expected meats to be stored on the bottom shelf of the walk-in cooler, with bread or cakes stored on higher shelves. The facility's policy, revised in October 2017, requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, which was not adhered to in these instances.
Failure to Update Care Plan for Resident with Trust Issues
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a diagnosis of bipolar disorder and non-Alzheimer's dementia, who exhibited moderate cognitive impairment. The Minimum Data Set (MDS) assessment indicated that it was very important for the resident to take care of their personal belongings and choose their clothing. However, the resident reported frequent issues with missing laundry items, which were not addressed in the care plan. Interviews with staff revealed that the resident had a history of trust issues and had previously reported missing laundry, but the care plan was not updated to reflect these concerns or include effective interventions. The facility's policy on comprehensive person-centered care plans required that care plans be updated with interventions after data gathering and when there is a change in the resident's condition. Despite this, the care plan for the resident did not include information about the resident's history of making statements about missing laundry items. Staff interviews confirmed that the care plan should have been updated to address the resident's behavior and trust issues, but this was not done, leading to the deficiency.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to follow physician's orders and implement necessary interventions to prevent pressure ulcer development for a resident at high risk. The resident, who had diagnoses of diabetes, cancer, and a hip fracture, was on hospice care and had severely impaired cognition. The care plan required frequent repositioning, heel floating, and the use of foot protectors while in bed. However, observations revealed that the resident was often without the prescribed bunny boots, both in bed and while seated in a chair, contrary to the physician's orders and care plan directives. Interviews with staff, including a CNA, CMA, LPN, MDS Coordinator, and the DON, confirmed inconsistencies in the application of protective boots. Staff reported that protective boots were documented as being used, but observations showed otherwise. The facility's policy on pressure injury prevention emphasized the use of medical devices and support surfaces to minimize tissue damage, yet these were not consistently applied for the resident, leading to a deficiency in care.
Failure to Provide Finger Foods as Per Resident Preference
Penalty
Summary
The facility failed to provide a diet with finger foods per resident preference to maintain nutrition and weight for a resident with Alzheimer's disease, dementia, GERD, diabetes, and anemia. The resident was on hospice care and had a severely impaired cognition score. The care plan indicated the resident was at nutritional risk due to diminished appetite and significant weight loss, with directives to provide finger foods and honor food preferences. Despite these directives, observations revealed that the resident was not consistently provided with finger foods, and staff did not assist or cue the resident during meals, leading to untouched meals. The resident's weight fluctuated significantly over several months, with a noted weight loss deemed unavoidable. The resident's care plan included a general diet with regular texture and finger foods, along with a nutritional supplement. However, observations showed that the meals provided did not always align with the finger food diet, as items like bread with pot pie, spinach, and pudding were not considered finger foods by the dietician. The dietician had previously provided staff education on finger foods but noted that the meals served did not adhere to the resident's dietary needs. Interviews with staff, including the LPN, RD, and DON, revealed inconsistencies in the understanding and implementation of the resident's dietary requirements. The RD acknowledged that certain items served were inappropriate for a finger food diet and planned to provide further education to the kitchen staff. The DON expressed concerns that limiting the diet to finger foods might result in the resident eating less, indicating a lack of adherence to the resident's dietary preferences and needs.
Failure to Post Required Notifications and Survey Results
Penalty
Summary
The facility failed to comply with regulatory requirements by not posting necessary notifications regarding survey agencies and advocacy support in areas accessible to residents. During a survey conducted over several days, it was observed that there was no information displayed on how to contact state agencies, and previous survey results were not made available within the facility. An interview with the Administrator and other staff revealed that the required postings, including contact information for state regulatory and informational agencies, were missing. Additionally, the binder containing previous survey results was outdated, with no updates since 2021, which the Administrator confirmed. This lack of updated information and accessibility to survey results constitutes a deficiency in meeting the residents' rights to receive notices in a format and language they understand.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
