Bethany Life
Inspection history, citations, penalties and survey trends for this long-term care facility in Story City, Iowa.
- Location
- 212 Lafayette Street, Story City, Iowa 50248
- CMS Provider Number
- 165424
- Inspections on file
- 31
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Bethany Life during CMS and state inspections, most recent first.
A cognitively intact resident who required total assistance with toileting and was frequently incontinent told a CNA during a nighttime incontinence round that she was dry and did not want to be bothered. Despite this refusal, the CNA proceeded to check her by placing a hand between her thighs to feel the outside of her brief, then left without changing her. On a subsequent round, the resident again refused to be checked, and the CNA then obtained the nurse. The resident later reported feeling uncomfortable, fearful that her wishes would not be respected, and having trouble sleeping after the incident. Staff interviews and documentation confirmed the resident’s account and that the action conflicted with the resident’s care plan and stated rights to dignity and self-determination.
A resident with moderately impaired cognition, dementia diagnoses, significant visual impairments, and identified on the care plan as an elopement risk who wore a wander alert pendant left the facility through a north door and later returned with staff, but this incident was not documented in the clinical record. Facility records showed conflicting information about the resident’s assigned household, and despite established expectations in the nurse competency checklist that unusual events and incidents be documented, the DON decided not to document the occurrence because it was not considered an actual elopement.
A resident with a history of CHF, hypertension, and renal failure did not receive prescribed PRN Lasix when their weight increased by 3 pounds from baseline, as directed by the physician. Despite clear orders and documentation of weight increases, staff did not administer the diuretic on several occasions, and this was confirmed through record review and staff interview.
A resident with multiple diagnoses, including anxiety and insomnia, did not receive medications as ordered when staff administered lorazepam at night instead of the prescribed clonazepam, and missed several doses of clonazepam. This led to increased anxiety, insomnia, and a hospital evaluation. Staff interviews confirmed confusion between the two medications, and facility policy requiring correct medication administration was not followed.
Two residents with documented histories of sexually inappropriate behaviors and cognitive impairment were left unsupervised together, resulting in an incident of sexual abuse. Despite care plans indicating the need for constant supervision and staff awareness of the risks, only general directives to keep the residents apart were given, and no additional interventions were implemented. Staff reported challenges in supervision due to staffing levels and the residents' mobility, and facility leadership acknowledged the lack of adequate supervision and specific instructions.
A resident with moderately impaired cognition and requiring assistance with mobility experienced a delay in call light response, taking over 19 minutes for staff to respond. Interviews with CNAs confirmed that call light responses often exceeded the expected 15-minute timeframe, contrary to state and federal regulations.
A resident who required substantial assistance for transfers fell and sustained fractures after a CNA failed to use a gait belt, despite the resident's request and facility policy. The CNA was terminated for this violation.
A resident with dysphagia, dementia, and a history of stroke was not adequately supervised during meal times, leading to a choking incident. Despite documented needs for eating cues and specific Care Plan instructions, staff failed to provide necessary supervision. The CNA responsible was preoccupied with other tasks and did not notice the resident choking until alerted by another staff member. This incident underscores the importance of adhering to individualized care requirements, particularly for residents with swallowing difficulties.
The facility failed to respond to call lights in a timely manner for four residents, leading to significant delays in care. One resident had to take herself to the bathroom, another remained in bed due to lack of staff, and a third resident's wife had to leave the unit to find help after a fall. The facility's policy requires call lights to be answered within 15 minutes, but this was not adhered to.
The facility failed to document a critical incident in a resident's medical record following their death. The resident, who had dysphagia, dementia, and a history of stroke, experienced a hypoxic episode after consuming a brownie. Despite attempts to perform the Heimlich maneuver, the resident did not recover, and the incident was not documented until two weeks later, after the survey began.
The facility failed to ensure liquid Lorazepam was stored in locked compartments in two medication rooms and did not maintain medication refrigerators properly, leading to ice build-up and unclear responsibilities for cleaning and defrosting. Staff interviews and observations revealed issues with lock management and a lack of clear policies.
The facility failed to serve food at safe and palatable temperatures in the Sansgaard Household. Observations revealed several food items below the required 140 degrees Fahrenheit, and residents reported receiving cold meals. Staff D, unfamiliar with the household's temperature chart, did not reheat the food as per facility policy.
A resident with severe cognitive impairment was subjected to loud and stern communication by a CMA, causing visible distress. Despite the facility's protocol for handling resistant residents, the staff member's actions did not align with expectations for treating residents with dignity and respect.
The facility failed to update the care plan for a resident with severe cognitive impairment and multiple diagnoses, who developed an unstageable pressure ulcer. Despite the facility's protocol requiring a care plan intervention within 72 hours, the care plan lacked a focus area related to the pressure ulcer, which had been assessed and measured weekly since its discovery.
The facility failed to complete weekly skin assessments for a resident with severe cognitive impairment and multiple diagnoses, as required by the Care Plan and physician's orders. Documentation was missing for several weeks in 2023 and 2024, and staff interviews confirmed the assessments were not completed as mandated.
The facility's Dietary Staff failed to follow proper procedures for pureed food preparation for seven residents on a pureed diet. The cook did not measure the volume of pureed food and used water instead of nutritional fluids, contrary to the facility's policy. The Dietician confirmed that the observed process did not adhere to the guidelines.
The facility failed to provide appropriate catheter care for a resident with a suprapubic catheter. During an observation, a staff member was seen escorting the resident with catheter tubing dragging on the ground, which the resident stepped on multiple times. Interviews revealed that the resident often resists catheter care, and staff usually place excess tubing in a dignity bag, which was not done during the incident.
The facility failed to complete a discharge summary, including a recapitulation of stay, for a resident. The resident's electronic health record did not contain a discharge summary or a post-discharge plan of care. The Administrator confirmed that the recapitulation is done through the discharge progress note and that the facility had no interdisciplinary form or policy on recapitulation of stay.
Failure to Honor Resident Refusal and Maintain Dignity During Incontinence Check
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to refuse care and to be treated with dignity and respect. Resident #1, who had a BIMS score of 14 indicating intact cognition, adequate hearing and vision, and no behavior issues, required total staff assistance with toileting and hygiene and was frequently incontinent of bowel. The resident’s care plan directed staff to follow facility protocol as the resident allowed for incontinence care, to assist with toileting, and to ask yes/no questions to determine the resident’s needs. An intervention also documented that the resident preferred to be changed between 1:00 AM and 3:00 AM. On the overnight shift at approximately 2:00 AM, Staff A, a CNA, entered Resident #1’s room to perform a check and change. Resident #1 told Staff A that she was dry and did not want to be bothered. Despite this clear refusal, Staff A proceeded to check the resident by placing a hand between the resident’s thighs to feel the outside of the brief. Resident #1 reported that she was dry and that the gesture made her uncomfortable. Staff A then left without changing the resident. During the next rounds, when Staff A again attempted to check the resident, Resident #1 again stated she did not want to be bothered, and at that point Staff A stepped away and obtained the nurse. Resident #1 later reported the incident to staff, including therapy and nursing personnel, describing that Staff A had placed hands between her thighs to check the brief after she had refused care. The resident stated that she felt uncomfortable and fearful that Staff A would not respect her wishes regarding being checked and changed, and she reported having trouble sleeping related to the incident. Multiple staff interviews, including with the RN, CNA, Occupational Therapy Assistant, Social Services, and the DON, confirmed that the resident had described the same sequence of events and that Staff A acknowledged proceeding with the check despite the resident’s refusal. The facility’s own Resident Rights acknowledgement stated that residents must be cared for in a manner that promotes maintenance or enhancement of quality of life and dignity, in full recognition of individuality, which was not followed in this incident.
Failure to Document Incident Involving Elopement-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to document an incident in which a resident left the facility unattended and later returned with staff. The resident had a BIMS score of 9, indicating moderately impaired cognition, and diagnoses including hypertension, Alzheimer’s disease, non-Alzheimer’s dementia, cataracts, glaucoma, and macular degeneration. The MDS documented that the resident could understand and be understood, had no documented behaviors such as wandering or rejecting care, and was independent with personal hygiene and ambulation using a 4-wheeled walker. The care plan, however, identified the resident as an elopement risk/wanderer related to impaired safety awareness, noted that the resident wore a wander alert pendant, and was independent with mobility. Facility records showed conflicting information about the resident’s assigned household, with the Wanderguard list indicating the Life Bridges household and a resident list report indicating a different household. The DON and ADON explained that the resident lived in the Life Bridges household and had gone out the north door of the facility, where the resident was usually supervised when outside. The DON stated that because the resident did not “actually elope,” the facility decided it was not necessary to document the incident in the clinical record. Upon later review, the DON acknowledged that staff are expected to document any incidents or unusual occurrences in the clinical record for all residents. The facility’s Nurse Competency Check Off List, reviewed on 6/24/24, required documentation of follow-up notes, family communication, hot charting, changes in condition, behaviors, new skin issues, unusual events, and alleged abuse, indicating that documentation of such incidents was an expected standard that was not followed in this case.
Failure to Administer Diuretic as Ordered for Weight Gain
Penalty
Summary
The facility failed to follow a physician's order for medication administration, resulting in a resident not receiving their prescribed diuretic (Lasix) as needed when their weight increased by 3 pounds from baseline. The resident, who had diagnoses including congestive heart failure, hypertension, renal and respiratory failure, and required supervision or partial assistance with activities of daily living, was to receive Lasix 20 mg orally daily as needed for weight gain. Clinical records and the Medication Administration Record (MAR) showed that on several occasions when the resident's weight met or exceeded the threshold for administration, the medication was not given as ordered. The care plan and physician orders specifically directed staff to monitor daily weights and administer Lasix accordingly. Despite these instructions, documentation revealed that the resident's weight increased above the baseline on multiple dates without the corresponding administration of the diuretic. Staff interviews confirmed that nurses were expected to follow physician orders as written, but the review of the clinical record indicated this did not occur, resulting in the resident not receiving the medication as prescribed.
Failure to Administer Medications per Physician Orders Resulting in Significant Medication Errors
Penalty
Summary
A deficiency occurred when staff failed to administer medications according to physician orders for a resident with chronic kidney disease, generalized anxiety disorder, major depressive disorder, and primary insomnia. The resident required substantial assistance with mobility and was dependent on staff for transfers and toileting. The care plan and medication administration record directed staff to administer lorazepam before meals and clonazepam at bedtime for anxiety. However, review of medication records revealed that the resident received an extra dose of lorazepam at bedtime on multiple occasions and missed several doses of clonazepam at night. The medication error was identified when a Certified Medication Aide (CMA) noticed that clonazepam had only been signed out every other night, and further review showed that lorazepam was being given at night instead of clonazepam. Progress notes documented that during this period, the resident experienced increased anxiety, shakiness, insomnia, and reported not feeling well. The resident and her family expressed concerns about her condition, leading to a hospital evaluation where acute insomnia and mood changes were noted. The facility's documentation also showed that on one occasion, a dose of lorazepam was omitted in the afternoon. Interviews with staff confirmed that the CMA confused the two medications and administered them incorrectly. The nurse practitioner indicated that the resident's symptoms of increased anxiety and difficulty sleeping could be related to receiving the shorter-acting lorazepam instead of the longer-acting clonazepam at night. The facility's policy required staff to follow the five rights of medication administration, but this was not adhered to in this case, resulting in significant medication errors for the resident.
Failure to Supervise Residents with Known Sexual Behaviors
Penalty
Summary
The facility failed to provide adequate supervision to prevent sexual abuse and inappropriate contact between two residents, both of whom had documented histories of sexually inappropriate behaviors and cognitive impairments. One resident, with moderate cognitive impairment and a history of sexually inappropriate advances toward others, was care planned to require supervision at all times and interventions to prevent inappropriate interactions. Despite these documented needs, the resident was able to be alone in her room with another resident, who also had a history of sexual inappropriateness and severe cognitive impairment. Staff discovered the two residents in a compromising position, with both partially undressed and the male resident on top of the female resident. Prior to the incident, both residents had exhibited repeated sexually inappropriate behaviors, including attempts to enter other residents' rooms, inappropriate touching, and making sexual advances toward peers and staff. These behaviors were documented in clinical records and care plans, and staff were aware of the risks associated with both individuals. Staff interviews revealed that the only directive given was to attempt to keep the two residents apart, but no additional supervision or specific interventions were implemented, despite the known risks and previous incidents. Staff also reported difficulty in providing close supervision due to staffing levels and the residents' ability to move independently and quickly. The lack of clear directives and insufficient supervision allowed the two residents to be unsupervised together, resulting in the observed incident. The facility's failure to implement effective interventions and provide adequate supervision, as outlined in the residents' care plans and based on their behavioral histories, directly led to the deficiency. The administration and nursing leadership acknowledged that the facility did not provide adequate nursing supervision or specific instructions to staff to prevent such incidents, despite being aware of the residents' behaviors.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility staff failed to respond to resident call lights in a timely manner, specifically for one resident who was reviewed. This resident, identified as having moderately impaired cognition with a BIMS score of 12, required assistance with toilet hygiene and transfers due to conditions such as Alzheimer's disease, non-Alzheimer's dementia, and osteoarthritis. The resident reported that it took over 30 minutes for staff to respond to their call light, which was corroborated by the Alarm Response Report showing a response time of over 19 minutes. Interviews with facility staff, including two Certified Nursing Assistants, confirmed that it could take over 15 minutes to answer call lights, which is against the facility's expectations and state and federal regulations. The facility's administrator also confirmed the expectation for staff to respond to call lights within 15 minutes. This deficiency was identified in a facility with a census of 117 residents, highlighting a failure to provide adequate staffing to meet the needs of every resident as required.
Failure to Use Gait Belt Results in Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and the use of a gait belt for Resident #6, who required substantial assistance for toilet transfers and total dependence for walking. On the morning of 4/22/24, Staff A, a CNA, assisted Resident #6 to the bathroom without using a gait belt, despite the resident's care plan specifying its necessity. As Resident #6 backed into the bathroom, her walker tipped sideways, causing her to bend at the knees and fall. This incident resulted in Resident #6 sustaining fractures to her toes and requiring a transfer to the local emergency department for further evaluation and treatment. Resident #6's Minimum Data Set (MDS) assessment indicated moderately impaired cognitive skills and a need for substantial assistance with daily activities due to conditions such as polyosteoarthritis and a recent left knee replacement. Despite the resident's request for the use of a gait belt, Staff A did not comply, citing the loss of her gait belt and not attempting to obtain a replacement. The facility's policy mandates the use of gait belts for all staff-assisted transfers, and Staff A had previously acknowledged this requirement and received training and a gait belt from the facility. The Director of Nursing (DON) confirmed that the facility provides gait belts and educates staff on their use, with replacements available at the front desk. Following the incident, the facility terminated Staff A for violating the gait belt policy. Observations and interviews with Resident #6 and staff corroborated the failure to use the gait belt, leading to the resident's fall and subsequent injuries.
Inadequate Supervision During Mealtime for Resident with Dysphagia
Penalty
Summary
The report details a critical deficiency in a nursing home setting where a resident (Resident #1) with a history of dysphagia, dementia, and stroke was not adequately supervised during meal times, leading to a tragic incident. Despite the resident's documented need for cues to slow down while eating and the presence of specific instructions in the Care Plan, the staff failed to provide the necessary supervision. This lack of oversight resulted in the resident choking on his dessert, leading to a fatal outcome. The incident highlighted a failure in the facility's supervision protocols and staff awareness of residents' individual needs, particularly in relation to mealtime safety for those with swallowing difficulties. The deficiency was exacerbated by the staff's failure to monitor Resident #1 closely during meal service, as evidenced by statements from various staff members involved in the incident. Despite clear instructions in the Care Plan and prior communication from the resident's family regarding his specific needs during meals, the staff did not provide the required level of supervision. The report indicates that the Certified Nursing Assistant (CNA) responsible for serving the resident's meal was preoccupied with other tasks and did not notice the resident choking until alerted by another staff member. This lack of attentiveness and failure to adhere to the resident's individualized care requirements contributed to the adverse outcome.
Failure to Respond to Call Lights in a Timely Manner
Penalty
Summary
The facility failed to ensure call lights were responded to in a timely manner for four residents, leading to significant delays in care. Resident #8 reported having to wait a long time for assistance to use the bathroom, resulting in her taking herself. The Alarm Response Report indicated that her call light was on for 17 minutes on one occasion and 29 minutes on another. Resident #9 expressed that she often remains in bed because there is not enough staff to transfer her to her wheelchair, and her call light was on for durations ranging from 17 to 24 minutes on multiple occasions. Resident #10's wife had to leave the unit to find help after the call light was not answered for 23 minutes, and Resident #10 was found on the ground after a fall. Resident #11 also reported delays in call light responses, with instances of waiting up to 43 minutes for assistance. The facility's policy on call light response, which mandates that call lights be answered within 15 minutes, was not adhered to. The Director of Nursing confirmed that the expectation is for all call lights to be answered within this timeframe. The documented delays in responding to call lights for Residents #8, #9, #10, and #11 indicate a failure to meet this policy, resulting in unmet needs and potential safety risks for the residents involved.
Failure to Document Critical Incident in Resident's Medical Record
Penalty
Summary
The facility failed to provide accurate resident records for one resident following their death. The clinical record for the resident, who had diagnoses of dysphagia, dementia, and a history of stroke, lacked documentation regarding a hypoxic episode that led to the resident's death. The incident occurred after the resident consumed a brownie and began coughing, showing signs of hypoxia. Despite attempts by multiple staff to perform the Heimlich maneuver, the resident did not recover, and emergency responders took over. However, the incident was not documented in the resident's electronic health record until after the survey began, two weeks later. The facility's policies on medical record documentation require that each resident's medical record contain an accurate representation of their experiences, including timely documentation of incidents. The Director of Nursing confirmed that incidents should be charted in the resident's chart. Despite these policies, the facility failed to document the critical incident in the resident's medical record, resulting in a deficiency noted by the surveyors.
Failure to Secure Controlled Substances and Maintain Medication Refrigerators
Penalty
Summary
The facility staff failed to ensure liquid Lorazepam, a controlled substance, was stored in a locked compartment in the refrigerator in two of the four medication rooms reviewed. Observations revealed that the medication refrigerators in the Lifebridge and David's Place households were unlocked, allowing access to liquid Lorazepam by nurses and certified medication assistants (CMAs). Staff interviews confirmed that the medication refrigerators were not consistently locked, and there was confusion among staff regarding the responsibility for locking the refrigerators and handling the keys. The Director of Nursing (DON) acknowledged that liquid Lorazepam and other controlled substances requiring refrigeration needed to be double locked, but issues with the medication refrigerator lock and key management were reported. Additionally, the facility failed to maintain safe operating equipment and ensure medication refrigerators were kept clean and free of ice build-up. Observations of the Lifebridge and David's Place medication refrigerators revealed a heavy build-up of ice in the freezer compartments, which contained various medications, including vaccines and antibiotics. Staff interviews indicated a lack of clarity regarding who was responsible for cleaning and defrosting the medication refrigerators. Maintenance staff reported not receiving any work orders for medication refrigerator repairs or defrosting in a long time, and there was no facility policy for medication refrigerator cleaning. The facility's failure to properly store controlled substances and maintain medication refrigerators in a clean and functional state was further highlighted by the lack of a clear policy and communication among staff. The CDC guidelines emphasize the importance of maintaining and repairing equipment to ensure the safety and efficacy of medications and vaccines. The facility's deficiencies in these areas were evident through staff interviews and observations, revealing a need for improved procedures and accountability in medication storage and equipment maintenance.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to prepare and serve all foods at a safe and palatable temperature in the Sansgaard Household, as observed during a survey. Two of ten interviewable residents reported that food temperatures were often not hot when meals were served. During an observation, Staff D, a homemaker, checked the food temperatures before serving lunch and found several items below the required 140 degrees Fahrenheit. For example, hamburger patties were at 131.5 degrees Fahrenheit, and ground beef noodles were at 110 degrees Fahrenheit. By the time the last resident was served, the temperatures had dropped further, with hamburger patties at 115 degrees Fahrenheit and fortified mashed potatoes at 108 degrees Fahrenheit. One resident reported receiving a room tray with cold soup and a not-hot grilled cheese sandwich. Staff D, who was assigned to the Sansgaard Household for the day, reported that she normally worked in another household and was unaware of where the temperature chart was kept in the Sansgaard Household. The facility's Food Temperature policy required all hot food items to be served at least at 140 degrees Fahrenheit, and if food needed reheating, it should be heated to 165 degrees Fahrenheit. The Dietician confirmed that food temperatures should be checked in the main kitchen and again before serving in the households, and any food below 140 degrees Fahrenheit should be reheated to 165 degrees Fahrenheit before serving.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as observed by state facility surveyors. On 2/28/24, Resident #91, who has severe cognitive impairment, Down Syndrome, and Obsessive-compulsive disorder, was subjected to loud and stern communication by Staff H, a Certified Medication Aide (CMA). Staff H demanded the resident go to the table to eat and made comments about the resident's sister in a frustrated tone, causing the resident to appear red, flushed, and tearful. When surveyors entered the unit, Staff H changed her tone but continued to speak loudly and sternly to the resident, further upsetting him. The resident complied with Staff H's demands but remained visibly distressed. Interviews with other staff members, including a Certified Nursing Assistant (CNA) and the Director of Nursing (DON), revealed that the facility's protocol for handling resistant residents involves walking away, giving the resident time, and re-approaching them. Staff are required to complete annual dementia care training and mandatory Relias training. Despite these protocols and training, Staff H's actions did not align with the facility's expectations for treating residents with dignity and respect, leading to the observed deficiency.
Failure to Update Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with a pressure ulcer. The resident, who had severe cognitive impairment and multiple diagnoses including Parkinson's disease, major depressive disorder, dementia, chronic pain, and polyneuropathy, was totally dependent on staff for personal hygiene, toileting, bathing, and transferring. The resident was always incontinent of bowel and bladder and had a pressure-reducing device for his bed and chair. Despite these conditions, the care plan lacked a focus area related to the pressure ulcer identified on 1/23/24, which was noted to be unstageable and had been assessed and measured weekly since its discovery. The treatment for the pressure ulcer was completed as ordered, but the care plan had not been updated to include this new focus area, contrary to the facility's protocol that required a care plan intervention within 72 hours of identifying a new wound. In an interview, the MDS Coordinator confirmed that the facility's protocol was to have a care plan intervention in place within 72 hours and to put immediate interventions in place for staff to address the issue. The facility's policy on comprehensive care plans stated that the care plan would be reviewed and revised after each comprehensive and quarterly MDS, and responsible staff would be informed of the interventions identified in the care plan. However, the care plan for this resident had not been updated to include the pressure ulcer, indicating a failure to follow the established protocol and policy.
Failure to Complete Weekly Skin Assessments
Penalty
Summary
The facility failed to complete weekly skin assessments for Resident #62 as required by the resident's comprehensive, person-centered Care Plan. Resident #62, who has severe cognitive impairment and diagnoses including non-traumatic brain dysfunction, diabetes mellitus, and non-Alzheimer's dementia, was supposed to have weekly skin inspections. However, documentation of these assessments was missing for multiple weeks in 2023 and 2024. The Care Plan, revised on 11/25/22, specifically directed staff to complete a skin inspection weekly, and an order from the resident's primary physician on 9/28/2022 also mandated a weekly Skin & Pain Assessment every Wednesday evening. Despite these directives, the electronic health records showed a lack of documentation for the specified weeks, indicating that the assessments were not completed as required. Interviews with staff, including a certified medication aide (CMA) and the Director of Nursing (DON), confirmed that the weekly skin assessments were not documented. The DON explained that the CMA had marked the treatment administration record (TAR) as completed, which did not trigger the nursing staff to complete the skin assessment report. Only nursing staff are authorized to complete these assessments, and they typically do so on the resident's first shower day of the week, which is Wednesday for Resident #62. The facility's Skin Assessment Policy, reviewed on 9/25/23, instructed staff to document the skin assessment comprehensively, but this was not adhered to in the case of Resident #62.
Deficiency in Pureed Food Preparation Process
Penalty
Summary
The facility's Dietary Staff failed to perform the proper functions of food and nutrition services for the pureed food process for seven residents requiring a pureed diet. During an observation, the cook, Staff J, did not measure the volume of pureed food after pureeing green beans, beef and noodle mixture, caramel apple dessert, and grilled cheese sandwiches. Instead, Staff J used a pre-prepared spreadsheet to determine the scoop size for each resident. Staff J also used water instead of fluids that add nutritional value, such as broth, milk, or juice, which is against the facility's puree policy and guidelines. During interviews, Staff J confirmed that she does not measure the volume of pureed food and relies on the spreadsheet for scoop sizes. The Dietician stated that kitchen staff should measure the volume after pureeing and use appropriate fluids to add nutritional value. The Dietician acknowledged that the observed process did not follow the facility's puree policy and guidelines. The facility's Puree Food Preparation Policy directs staff to measure servings before pureeing, use appropriate fluids, and measure the total volume after pureeing, which was not followed in this instance.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care for Resident #91, who has Down Syndrome with intellectual disability and neurological dysfunction of the bladder requiring a suprapubic catheter. During a direct observation, Staff H was seen escorting Resident #91 back to their room with a significant length of catheter tubing dragging on the ground, which the resident stepped on multiple times. Staff H did not take any action to correct the issue. Interviews with Staff B and Staff X revealed that Resident #91 often resists catheter care and will not tolerate securing the tubing to their leg. Instead, they place the excess tubing in a dignity bag, which was not done during the observed incident.
Failure to Complete Discharge Summary and Recapitulation of Stay
Penalty
Summary
The facility failed to complete a discharge summary, including a recapitulation of stay, for one of the three discharged residents reviewed. The resident was admitted on an unspecified date and discharged on 12/5/23. The progress note documented that the resident was picked up by her advocate, and all personal items, medications, treatments, and a list of appointments were sent with her. However, the resident's electronic health record did not contain a discharge summary or a post-discharge plan of care. The Administrator confirmed that the recapitulation is done through the discharge progress note and that the facility had no interdisciplinary form or policy on recapitulation of stay.
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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