Belle Plaine Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Belle Plaine, Iowa.
- Location
- 1505 Sunset Drive, Belle Plaine, Iowa 52208
- CMS Provider Number
- 165349
- Inspections on file
- 22
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Belle Plaine Specialty Care during CMS and state inspections, most recent first.
A resident with moderately impaired cognition, who was non-ambulatory and used a wheelchair, was mistakenly given a full set of medications prescribed for another resident when an LPN on her second shift, still in orientation, misidentified him in the dining room. The LPN prepared and administered multiple medications, including cardiac, antihypertensive, and antidiabetic drugs, after the resident responded to the wrong name, and did not verify identity using the medical record photograph as required by facility policy. The orienting LPN had briefly left the new LPN alone and discovered the error upon returning, when she saw the new LPN about to administer eye drops that the resident did not receive.
Two residents with severe cognitive impairment were not treated with dignity during care. One was verbally berated and physically mishandled by an RN after repeated falls, with no assessment or documentation. Another was transferred without a mechanical lift by a CNA, resulting in bruising and distress, despite her care plan requiring total assistance. Staff interviews confirmed failures to follow care plans and use respectful communication.
A resident dependent on staff for care experienced a fall that resulted in the accidental removal of a suprapubic catheter. Staff observed the catheter was missing but did not provide timely assessment or intervention, and the care plan lacked guidance for such an event. The resident went several hours without appropriate care, resulting in prolonged urine leakage and the inability to replace the catheter at the hospital, necessitating a Foley catheter instead.
A resident with severe cognitive impairment and total dependence for transfers was manually transferred by a CNA without the required mechanical lift or second staff member, contrary to the Care Plan. The resident was observed to be in distress during the transfer and was later found with significant bruising on both arms. Staff interviews confirmed the transfer was performed unsafely and without proper assistance, leading to preventable injuries.
A resident with moderate cognitive impairment and diabetes experienced a significant decline in health, including rapid weight loss and decreased intake, without adequate assessment or documentation by the facility. The resident's condition worsened, leading to a metabolic crisis and hospitalization. Staff interviews revealed inconsistencies in monitoring and communication, and the facility's policy on changes in condition was not followed.
The facility failed to serve the correct mechanical soft diet to several residents, including one who was served a whole fish patty instead of ground fish. The error was identified by the Registered Dietitian before serving, except for one resident who consumed the incorrect meal. The Administrator and Nurse Consultant acknowledged the dietary errors.
A resident requested a room tray for her meal, which was delivered over an hour later than requested. Additionally, the facility provided plastic eating utensils instead of regular metal ones, which the resident preferred.
A facility failed to ensure timely provider responses to pharmacy recommendations for a resident's Sertraline dosage adjustment. Despite multiple requests from the Consultant Pharmacist, the provider did not address the recommendations in July and August, with a response only documented in September. The delay was attributed to the infrequent visits of the Mental Health Nurse Practitioner.
The facility failed to maintain safe food and beverage temperatures for room trays, with a test tray showing food below required hot temperatures and drinks above required cold temperatures. A resident reported receiving cold food, and Food Council meeting minutes documented ongoing concerns about food temperatures, which were acknowledged but not addressed by staff.
A resident's diet was changed from pureed to mechanical soft based on Speech Therapy's recommendation without obtaining a physician's order. The dietary staff served the resident a mechanical soft diet, unaware that the official order was not secured. The facility's policies require physician-prescribed therapeutic diets, and the trial period for the diet change exceeded the allowable time without an order.
Improper food handling practices were observed in the facility, where staff members failed to change gloves after touching various surfaces and objects before handling food. This was acknowledged by the Administrator and Nurse Consultant, and it contravenes the facility's policy on preventing foodborne illness.
Medication Error Due to Misidentification of Resident During Orientation
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of quality by administering a full set of medications intended for one resident to another. Resident #1, who had moderately impaired cognition with a BIMS score of 10 and was non-ambulatory and used a wheelchair, received multiple medications not prescribed for him, including aspirin, buspirone, calcium, carvedilol, vitamin D, glipizide, isosorbide, jardiance, lisinopril, metformin, and tamsulosin. A progress note by the ARNP documented that Resident #1 received medications he did not normally take in error. The error occurred when Staff A, an LPN on her second shift and still in orientation, was told by Staff B, an LPN, that Resident #6 was in the dining room and that she could give his medications. Staff A prepared the medications and, after asking for clarification on which resident was Resident #6, administered them to Resident #1, mistakenly believing he was Resident #6. Staff A called Resident #1 by Resident #6’s name and he responded, and she proceeded with administration until Staff B returned and noticed Staff A about to give eye drops to Resident #1, who did not receive eye drops. Staff B then verified that Resident #1 had received medications intended for Resident #6. The facility’s medication administration policy required staff to verify resident identity by checking the photograph in the medical record and, if necessary, confirming with other personnel, but this verification process was not followed.
Failure to Maintain Resident Dignity and Safe Care During Assistance and Transfers
Penalty
Summary
The facility failed to respect resident dignity and provide care in accordance with residents' rights for two residents with severe cognitive impairment. One resident with Parkinson's disease, muscle wasting, and repeated falls was dependent on staff for ambulation and required assistance with a walker and wheelchair. On the evening of her fall, staff interviews revealed that a registered nurse witnessed the resident fall, did not assess her or take vital signs, and responded with inappropriate and disrespectful language, including cursing at the resident and expressing frustration. The nurse physically lifted the resident from the floor by her arms and dragged her, without proper assessment or documentation of the incident. Other staff members reported feeling uncomfortable and concerned about the nurse's behavior, noting that the falls were not documented in the shift report and that the resident was visibly shaken and crying after the incidents. Another resident with muscle weakness and dementia, who required total assistance and mechanical lift transfers, was found to have significant bruising on both forearms. Staff interviews and documentation indicated that a CNA transferred the resident without the required mechanical lift, instead performing a manual pivot transfer and body lift. During the transfer, the resident was heard screaming in pain and fear, and was later observed to be visibly shaken and fearful. The CNA involved had only two days of training before working independently and admitted to transferring the resident without assistance or proper equipment. Other staff members witnessed the incident, reported their concerns to the nurse and DON, and noted that the resident's care plan was not followed during the transfer. The facility's policy requires that residents be free from abuse, neglect, and mistreatment, and that staff maintain a culture of compassion and caring, especially for those with cognitive or behavioral issues. Despite this, the actions and inactions of staff in both cases resulted in a failure to uphold resident dignity and provide care in a respectful and safe manner, as evidenced by inappropriate handling, lack of assessment, failure to follow care plans, and disrespectful communication.
Failure to Provide Timely Assessment and Intervention After Suprapubic Catheter Dislodgement
Penalty
Summary
The facility failed to provide appropriate assessment and timely intervention for a resident after a fall resulted in the accidental removal of a suprapubic urinary catheter. The resident, who had diagnoses including diabetes mellitus, chronic kidney disease, and urinary retention, was dependent on staff for transfers and personal care. After the fall, staff observed that the suprapubic catheter was missing and reported this to the nurse on duty. However, there was no immediate assessment or intervention for the catheter removal, and the care plan did not provide guidance for staff in the event of catheter dislodgement. Multiple staff interviews revealed that the catheter was noted to be missing around 2:30 PM, but the resident did not receive an appropriate nursing assessment or intervention for approximately seven hours. The oncoming nurse was not informed of the catheter removal during shift change, and only after being notified by CNAs did the nurse assess the resident and contact the physician. Emergency Medical Technicians were called, but the resident initially refused transport to the hospital. The resident later agreed to be transported, but by that time, the suprapubic stoma had closed, and a replacement catheter could not be inserted. Clinical documentation and interviews confirmed that the resident experienced prolonged leakage of urine from the abdominal opening, was confined to bed for several hours, and did not receive timely care for the catheter issue. The Emergency Department was unable to replace the suprapubic catheter due to the delay, and a Foley catheter was placed instead. The facility's care plan lacked specific instructions for staff in the event of suprapubic catheter dislodgement, contributing to the delay in appropriate care.
Failure to Follow Care Plan for Safe Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, muscle weakness, and total dependence for transfers was not safely transferred according to her Care Plan. The resident was non-ambulatory and required a mechanical lift with two staff for all transfers. Despite these requirements, a CNA transferred the resident without the mechanical lift and without a second staff member, instead performing a manual pivot transfer and body lift. This action was witnessed by other staff, who reported hearing the resident screaming in distress and observed the resident being roughly handled and repositioned in her wheelchair. Following the transfer, the resident was found to have significant bruising on both upper extremities, including a large dark purple bruise on the right forearm extending from above the elbow to the wrist, and a circular bruise on the left forearm above the wrist. The resident, who was confused and unable to verbalize how the injuries occurred, denied pain but appeared fearful and shaken. Multiple staff interviews confirmed that the resident was transferred without the required equipment and assistance, and that the CNA involved was aware of the Care Plan requirements but did not follow them. The incident was reported to nursing and administrative staff, and documentation confirmed the injuries were new and acquired in-house. Staff interviews revealed that the CNA had only two days of training before working independently and was not familiar with accessing Care Plans. Other staff expressed concerns about the CNA's handling of residents and reported the incident to the nurse and DON. The failure to follow the Care Plan and provide adequate supervision resulted in preventable injuries to the resident.
Failure to Assess and Document Resident's Decline
Penalty
Summary
The facility failed to adequately assess and document a resident's decline in condition over a three-day period, leading to a significant health crisis. The resident, who had moderate cognitive impairment and a history of diabetes, experienced a rapid decline in health, including significant weight loss and decreased food and fluid intake. Despite these changes, there was a lack of timely and thorough assessments, as well as inadequate documentation of the resident's condition and vital signs. The resident's medical record showed a lack of consistent monitoring and communication with the attending physician regarding the resident's deteriorating condition. The last recorded blood sugar level was from several months prior, and there was no documentation of the physician being notified about the resident's limited oral intake. The resident's condition worsened, culminating in a metabolic crisis with a critically high blood sugar level upon arrival at the hospital. Interviews with staff revealed inconsistencies in the monitoring and assessment of the resident's condition, particularly regarding the administration of breathing treatments and the assessment of breath sounds. The facility's policy on changes in a resident's condition was not adequately followed, as evidenced by the lack of timely notification to the resident's power of attorney and the absence of a comprehensive assessment of the resident's health status during the critical period leading up to the hospital transfer.
Dietary Errors in Serving Mechanical Soft Diets
Penalty
Summary
The facility failed to provide the correct diet to residents requiring a mechanical soft texture diet. On the day of observation, Resident #27 was served a whole fish patty instead of ground fish, which was not in accordance with the physician's diet order. Additionally, the kitchen staff initially set up incorrect meals for Residents #12, #18, #26, and #28, who were also prescribed mechanical soft diets. The error was identified before serving due to the intervention of the Registered Dietitian, who noticed the mistake and instructed the staff to correct it. The incident involved a total of five residents who were supposed to receive a mechanical soft diet. The Registered Dietitian confirmed that all residents with such dietary requirements should have their fish ground. The Dietary Manager initially reported that Resident #27 had not eaten the meal, but later confirmed that the resident had consumed the fish after it was cut into small pieces by a CNA. The facility's failure to adhere to the prescribed dietary orders was acknowledged by the Administrator and the Nurse Consultant, who confirmed that the meals prepared did not meet the mechanical soft diet requirements.
Delayed Meal Service and Inappropriate Utensils for Resident
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination by not providing a timely meal service and appropriate eating utensils. On 10/15/24, at 12:33 PM, the administrator approached a resident's room to inquire if she would be dining in the dining room. The resident requested a room tray instead. However, the tray was not delivered until 1:38 PM, over an hour later. Additionally, when the tray was delivered, the resident was provided with plastic eating utensils instead of regular metal ones. During an interview at 1:47 PM, the resident expressed her preference for regular eating utensils over plastic ones.
Failure to Respond to Pharmacy Recommendations for Medication Adjustment
Penalty
Summary
The facility failed to ensure a provider responded to monthly pharmacy recommendations for a resident's medication regimen in July and August. The Consultant Pharmacist sent recommendations on two occasions, requesting a reduction in the dosage of Sertraline, an antidepressant medication, to 150 mg. These recommendations were not addressed by the provider, leading to a lack of documented response or action in the resident's health record. The facility's policy requires that such recommendations be acted upon or rejected with an explanation, and the attending physician should document any decisions made regarding the medication regimen. The deficiency involved a resident who was stable on their current medication regimen, as noted in a later response from the Mental Health Nurse Practitioner in September. The Nurse Practitioner expressed concerns that a dose reduction might impair the resident's function or cause psychiatric instability. However, this response came only after the third request from the Consultant Pharmacist, indicating a delay in addressing the initial recommendations. The Director of Nursing acknowledged the lack of timely responses to the earlier recommendations, attributing it to the Nurse Practitioner's infrequent visits.
Failure to Maintain Safe Food and Beverage Temperatures
Penalty
Summary
The facility failed to maintain appropriate food and beverage temperatures for room trays, as evidenced by a test tray that showed food temperatures below the required levels. During a lunchtime meal service, a test tray was checked immediately after the last room tray was served, revealing that the rice was at 133.7 degrees Fahrenheit and peas at 121.0 degrees Fahrenheit, both below the required 135 degrees Fahrenheit. Additionally, the chocolate milk and juice were above the required cold temperature, measuring 46.6 degrees Fahrenheit and 43.2 degrees Fahrenheit, respectively. Resident interviews and Food Council meeting minutes from February to May, as well as an undated meeting, documented ongoing concerns about cold food, which were acknowledged by facility staff but not addressed. Resident #5 specifically mentioned receiving cold food on room trays, highlighting the facility's failure to address these concerns despite repeated resident feedback.
Failure to Obtain Physician's Order for Diet Change
Penalty
Summary
The facility failed to obtain a physician's order for a change in diet for one resident, who was initially prescribed a pureed diet. Speech Therapy recommended upgrading the resident's diet from pureed to mechanical soft, but the facility did not secure a doctor's order for this change. Despite the absence of an official order, the dietary staff served the resident a mechanical soft diet. The Dietary Manager and Registered Dietitian were unaware of the change until questioned, and the Registered Dietitian's list still indicated the resident was to receive a pureed diet. The deficiency was acknowledged by the facility's Administrator and Nurse Consultant, who confirmed that the recommendation for a diet change was made by Speech Therapy a week prior, but no order was obtained until the day of the survey. The Director of Nursing mentioned that they were trialing the mechanical soft diet, but the trial period exceeded the allowable three days without an official order. The facility's policies require that therapeutic diets be prescribed by the attending physician and that any changes be communicated to the food and nutrition services department, which was not adhered to in this case.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to safe food handling practices during the preparation of sandwiches, as observed on multiple occasions. Staff B, a cook, was seen handling bread and spreading peanut butter with gloved hands, but then touched various surfaces and objects, such as cupboard doors and a plastic knife, without changing gloves before continuing to handle food. This improper use of gloves was repeated when Staff B touched a peanut butter container, jelly container, and a plate before making a sandwich, and then handled a potato chip bag and chips without changing gloves. Similarly, Staff D, another cook, was observed putting on gloves to spread butter on bread, but then touched a plate and continued to handle the bread without changing gloves. These actions were acknowledged by the Administrator and the Nurse Consultant, who recognized the issue of using gloved hands to touch food after contacting other objects. The facility's policy on preventing foodborne illness, revised in July 2014, emphasizes the importance of safe food handling to minimize the risk of foodborne illness, highlighting poor personal hygiene and contaminated equipment as critical factors.
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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