Bethany Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Council Bluffs, Iowa.
- Location
- Seven Elliott Street, Council Bluffs, Iowa 51503
- CMS Provider Number
- 165524
- Inspections on file
- 31
- Latest survey
- October 2, 2025
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Bethany Lutheran Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and chronic pain did not receive scheduled morphine for 11 days after a durational order was not renewed or sent to the pharmacy following a provider review. The medication remained active on the MAR, but no new script was generated, leading to withdrawal symptoms and an ER visit. Staff interviews confirmed the lapse was due to failure to renew the order and lack of follow-up on the provider's documentation.
A resident with a history of falls and recent changes in transfer needs was transferred by only one CNA, despite the care plan requiring two-person assistance. The CNA relied on an outdated care sheet in the room, resulting in the resident sustaining a toe injury during the transfer. The incident was due to a lack of updated and accessible care plan information for staff.
A resident with no cognitive impairment was administered morphine and Ativan without consent by a nurse, despite the resident's refusal. The nurse, assisted by another staff member, justified the action as necessary for safety due to the resident's aggressive behavior. The facility's investigation confirmed the violation of the resident's rights to refuse medication and maintain dignity.
A resident with no cognitive impairment became agitated and physically aggressive, throwing objects at staff. A nurse administered medications without the resident's consent, with assistance from another staff member. The incident was not reported to management within the required timeframe, violating the facility's reporting protocol.
The facility failed to update care plans for two residents, leading to deficiencies in their care. One resident, with severe cognitive impairment and on hospice care, had a care plan that did not reflect his current needs, including transfer status and catheter use. Another resident, at risk for falls, had an outdated care plan that did not address changes in transfer techniques or fall prevention measures. The absence of the staff member responsible for care plan updates contributed to these deficiencies.
A resident with no cognitive impairment, who often refused medications, exhibited confusion and aggressive behavior. Staff C, a CMA, improperly signed out medications that were administered by Staff E without the resident's consent, violating the facility's medication administration policy.
A long-term care facility failed to provide adequate nursing staff, resulting in delayed call light responses for multiple residents. One resident, frequently incontinent, experienced delays of up to an hour, while another, with a history of polio, waited 45 minutes, leading to urination in his chair. Staff cited short staffing as a reason for the delays, particularly during meal times and when shifts were understaffed.
The facility did not provide RN coverage for at least 8 consecutive hours a day for 7 days a week. The scheduled RN called in sick and walked out on consecutive days, leaving shifts unfilled. The Staff Coordinator and Administrator were aware of the situation but did not ensure coverage. The facility census was 85.
The facility failed to follow professional standards in food preparation and hand hygiene. Staff H did not perform hand hygiene before and after glove use while preparing food, and improperly checked food temperatures by piercing foil coverings. The Dining Services Manager confirmed these actions were against facility policies and CDC guidelines.
The facility failed to notify the LTC Ombudsman of a resident's hospitalization, as required. The resident was hospitalized without a signed bed hold or notification to the Ombudsman. Interviews with staff, including the DON and Social Services Director, confirmed the oversight, and the Administrator acknowledged the failure to notify.
A facility failed to provide a bed hold notice to a resident or their representative during a hospitalization period. The resident was hospitalized without receiving the required notice, as confirmed by record reviews and staff interviews. The facility's policy mandates providing a Bed Hold Notice form during such transfers, but this was not done, as acknowledged by the facility's Administrator.
The facility failed to refer two residents for a Level II PASRR evaluation despite serious mental disorders. One resident had a diagnosis of schizophrenia not included in the PASRR, and another had a diagnosis of unspecified psychosis not reflected in a new PASRR. The facility lacked a PASRR policy, relying on federal regulations.
A facility failed to address dementia care for a resident with severe cognitive impairment and multiple diagnoses, including non-Alzheimer's dementia and anxiety. The resident's care plan lacked information on dementia care, despite the facility's policy requiring individualized care plans. The DON acknowledged the oversight.
A facility failed to follow infection prevention practices during medication administration, catheter care, and wound care for three residents. A nurse poured medications into bare hands, a CNA did not perform hand hygiene or wear a gown during catheter care, and an LPN failed to perform hand hygiene and use enhanced barrier precautions during wound care. These actions were contrary to the facility's policies and infection control protocols.
A resident with a care plan requiring two-person assistance for repositioning was injured when only one CNA assisted her, resulting in a fall and a fractured femoral neck. The incident occurred due to the resident being too close to the edge of the bed and slipping off the grab bar. Staff interviews revealed a lack of awareness of the care plan requirements, and the facility's policies were reviewed.
A resident with spina bifida and other conditions fell from bed after a CNA, unaware of the care plan requiring two staff for repositioning, assisted alone. The care plan specified two staff members were needed, but the CNA believed only one was required. The DON confirmed the care plan's requirements, indicating a communication lapse in the facility.
The facility failed to treat five residents with dignity and respect, involving incidents of improper handling and communication by staff. One resident was taken to the shower room in his underwear, another was denied the use of a mechanical lift and told to urinate in his pants, and a third was verbally mistreated and told she could not walk. Additionally, two residents were observed being transported without proper covering, exposing their bodies inappropriately.
The facility failed to transfer two residents according to policy, resulting in physical harm and emotional distress. One resident was transferred using a mechanical lift by a single staff member, leading to injuries, while another resident was improperly transferred with a lift instead of a walker, causing emotional distress. Staff interviews confirmed non-compliance with the facility's policy requiring two staff members for transfers.
Failure to Administer Scheduled Morphine Due to Lapsed Order Renewal
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and chronic pain, who was prescribed morphine sulfate 15 mg twice daily for pain management, did not receive her scheduled morphine doses for 11 days. The morphine order was a durational order requiring review every 30 days by the Nurse Practitioner. After the Nurse Practitioner’s visit and documentation to continue the morphine, the order was not renewed or sent to the pharmacy, resulting in the medication not being available for administration. The Medication Administration Record (MAR) still showed the morphine as an active order, but no new script was generated, and the pharmacy did not receive a renewal request. During the period without her scheduled morphine, the resident exhibited withdrawal symptoms and was sent to the emergency room for evaluation. Progress notes indicated that the resident experienced vomiting, diarrhea, hypertension, and nonverbal signs of pain, such as grimacing and trembling. The resident’s daughter and hospice staff later became involved, and it was discovered that the morphine order had lapsed. The resident’s condition continued to decline, and she was unable to swallow medications or food in the days leading up to her death. Interviews with facility staff revealed that the lapse in medication administration was due to a failure to renew the morphine order after the Nurse Practitioner’s review. The Assistant Director of Nursing acknowledged that the order should have been written and sent to the pharmacy, and that nurses should have noticed the absence of the order. The Director of Nursing confirmed that the resident experienced opioid withdrawal as a result of not receiving her scheduled morphine. The facility’s policy required care and services to be provided according to the most recent medical orders, which was not followed in this case.
Failure to Update and Communicate Resident Transfer Requirements Leads to Injury
Penalty
Summary
A deficiency occurred when a resident, who had a history of falls and required the assistance of two staff members for transfers following a recent fall, was transferred by only one staff member. The resident's care plan had been updated to reflect the need for two-person assistance with a gait belt after her knee gave out during a previous transfer. However, the care sheet in the resident's room incorrectly indicated that only one staff member was needed for transfers. As a result, a staff member, relying on the outdated care sheet, attempted to transfer the resident alone using a gait belt and walker, rather than following the updated care plan requirements. During this transfer, the resident sustained an injury to her fourth toe, which became bruised and later developed a blackened toenail. The staff member involved was unaware of the updated transfer requirements in the electronic care plan and used the information from the care sheet in the resident's room. The incident highlighted a failure to ensure that staff had access to and followed the most current care plan information, leading to inadequate supervision and an accident during a transfer.
Violation of Resident's Right to Refuse Medication
Penalty
Summary
The facility failed to treat a resident with dignity during medication administration. The resident, who had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, was documented to have refused care such as medications at times. On the morning in question, the resident was observed to be confused and agitated, refusing medications and breakfast. The resident exhibited aggressive behavior by throwing objects at staff and was subsequently taken to her room where she continued to show signs of agitation. Staff E, a registered nurse, administered medications to the resident without her consent. Despite the resident's refusal, Staff E proceeded to give the resident morphine and Ativan, with the assistance of Staff F, who held the resident's head. Staff E justified her actions by stating she was trying to keep the resident and others safe, as the resident was exhibiting behaviors that could potentially cause harm. However, the administration of medication without the resident's consent was a violation of her rights. The facility's investigation concluded that Staff E did not allow the resident the right to refuse the medications, which was against the facility's policy. The Director of Nursing and the Administrator acknowledged that the situation could have been handled differently, suggesting that the resident needed space and time to calm down. The incident highlighted a failure to uphold the resident's rights to self-determination and dignity, as outlined in the facility's policy.
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required two-hour timeframe. The incident involved a resident with no cognitive impairment, who had a history of refusing care and medications. On the morning of the incident, the resident exhibited confusion and agitation, refusing medications and breakfast, and later became physically aggressive, throwing objects at staff and other residents. During the incident, the resident threw a cup at a nurse and another resident, and subsequently hit the nurse with another cup. The nurse, identified as Staff E, assisted the resident into a wheelchair and administered medications without the resident's consent, with the help of another staff member, Staff F, who held the resident's head. The resident was not given the option to refuse the medications, which included morphine and Ativan, despite expressing a desire not to take them due to previous hallucinations. The facility's investigation revealed that the nurse did not allow the resident the right to refuse medications and failed to report the incident to management in a timely manner. The facility's policy requires immediate reporting of such incidents to the charge nurse and the Administrator, and to the Iowa Department of Inspections and Appeals within two hours. However, the management was only informed the following day, indicating a breach in the facility's reporting protocol.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to review and revise the care plans for two residents, leading to deficiencies in their care. Resident #5, who had severe cognitive impairment and was receiving hospice care, had a care plan that did not reflect his current needs. The care plan failed to identify the resident's transfer status, positioning needs, and the presence of a catheter. Despite the resident's significant change in condition, including a hospital admission for a urinary tract infection and the initiation of hospice care, the care plan was not updated to include necessary interventions such as therapy services and reporting deterioration to the physician. Resident #6, who had normal cognition but was at risk for falls, also had an outdated care plan. The care plan did not reflect changes in the resident's transfer techniques, the use of a pressure relief cushion, or the need for enhanced barrier precautions. The resident had a history of falls, including a significant fall that resulted in a hip fracture, yet the care plan did not adequately address these risks. Observations showed that the resident was frequently left in a recliner with a sling under him, and the care plan did not include necessary interventions to prevent further falls. The deficiencies in the care plans were compounded by the absence of the staff member responsible for updating them, who was a full-time student and not present in the building. The Director of Nursing acknowledged the inaccuracies in the care plans and the need for more thorough audits and staff education. Despite the facility's efforts to improve care plan processes, the deficiencies indicate that there were still significant areas that required attention to ensure that resident needs were accurately reflected and addressed.
Improper Medication Administration to Resident
Penalty
Summary
The facility failed to adhere to professional standards in administering medications to a resident, identified as Resident #3, who had a history of refusing care and medications. The resident, with a BIMS score indicating no cognitive impairment, was diagnosed with chronic respiratory failure, atrial fibrillation, heart failure, and urine retention. On the morning of February 9, 2025, the resident exhibited confusion, agitation, and aggressive behavior, refusing medications and breakfast. Despite these behaviors, the staff did not follow proper medication administration procedures. Staff C, a Certified Medication Aide, was involved in the administration of medications to the resident. Although the resident refused medications earlier that morning, Staff C drew up morphine and provided the Ativan bottle to Staff E, who administered the medications without the resident's consent. Staff C signed out the medications as given, despite not being present during administration. This action was contrary to the facility's medication administration policy, which requires the staff administering the medication to document its administration and ensure the resident has taken it. The Director of Nursing confirmed that Staff C acknowledged her mistake and was educated on the proper procedure. Staff E admitted to medicating the resident without giving her a choice, citing the resident's dangerous behavior as justification. The facility's policy mandates that medications be administered per physician order and documented by the administering staff, which was not followed in this instance, leading to the deficiency.
Inadequate Staffing Leads to Delayed Call Light Responses
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Multiple residents reported significant delays in call light responses, with some waiting up to 59 minutes. Resident #54, who is frequently incontinent, experienced delays of up to an hour, impacting her ability to use the restroom and attend breakfast. The facility's alarm response report confirmed numerous instances where call light response times exceeded 15 minutes, with some delays lasting over 45 minutes. Resident #22, who requires assistance for toileting and has a history of polio, reported a 45-minute delay in call light response, resulting in urination in his chair. His care plan highlights a risk for injury due to his medical conditions, yet the facility's call light log showed multiple instances of delayed responses. Staff interviews revealed that short staffing frequently led to extended call light response times, particularly during meal times and when shifts were understaffed. Resident #289, admitted recently, also experienced delays in call light responses, with times exceeding 15 minutes on several occasions. This resident requires substantial assistance for transfers and has a fracture, emphasizing the need for timely staff response. Similarly, Resident #10, who is dependent on assistance for transfers and has end-stage renal disease, was observed without access to a call light, further highlighting the facility's failure to ensure resident safety. Staff acknowledged the delays, attributing them to staffing shortages and the need to manage residents with behavioral issues.
Failure to Provide RN Coverage for Required Hours
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least 8 consecutive hours a day for 7 days a week, as required by regulations. The deficiency occurred when the scheduled RN called in sick after being at work for less than 30 minutes on one day and walked out on the next day after looking at the schedule. The Staff Coordinator was aware of the situation but did not fill the position with another RN for the empty shifts. The Administrator, along with the Nurse Consultant, acknowledged the lack of RN coverage on these days, although the Administrator was not initially aware of the call-in on the first day. The facility census was 85 at the time of the deficiency.
Failure to Follow Food Safety and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to professional standards in food preparation, serving, and distribution, as observed during a survey. Staff H, a cook, was seen modifying an entree to a mechanical soft consistency without performing hand hygiene before donning a glove. Staff H used a gloved hand to handle the turkey and a non-gloved hand to operate the food processor, then compacted the turkey in a measuring cup with the gloved hand. After completing the task, Staff H removed the glove and disposed of it without performing hand hygiene before covering the food and placing it in the steam oven. Further observations revealed that Staff H did not consistently follow proper procedures when checking food temperatures, as they stabbed a thermometer through the aluminum foil covering the food, creating large holes. Additionally, during the preparation of buttered bread, Staff H used a single glove on one hand and did not perform hand hygiene before glove application. The Dining Services Manager confirmed that staff should not touch other items when using a gloved hand for food management and emphasized the importance of hand hygiene immediately after glove removal. The facility's policies and procedures, as well as CDC guidelines, were not followed, contributing to the deficiency.
Failure to Notify LTC Ombudsman of Resident's Hospitalization
Penalty
Summary
The facility failed to notify the Long-Term Care (LTC) Ombudsman of a resident's transfer to the hospital, which was identified during a clinical record review and staff interviews. Specifically, the facility did not provide notification for one of the six residents reviewed, who was hospitalized from June 2 to June 10, 2024. The facility's document, Notice of Transfer Form to LTC Ombudsman, for June 2024, lacked the required notice of this resident's hospitalization. Interviews with facility staff revealed that the Director of Nursing (DON) indicated that Social Services typically handled bed holds and notifications to the LTC Ombudsman, and the document should have been in the resident's chart. However, the Social Services Director confirmed that there was no signed bed hold or notification to the LTC Ombudsman for the resident's hospital admission. The Administrator acknowledged the oversight, confirming that the facility did not perform the necessary notification for the resident's hospitalization.
Failure to Provide Bed Hold Notice During Hospitalization
Penalty
Summary
The facility failed to provide a bed hold notice to a resident, the resident's representative, or the Power of Attorney (POA) during a hospitalization period. Specifically, Resident #26 was hospitalized from June 2, 2024, to June 10, 2024, without receiving a bed hold notice, as confirmed by a review of the resident's electronic and paper clinical records. Interviews with the Director of Nursing (DON) and the Social Services Director revealed that the responsibility for handling bed holds and notifying the LTC Ombudsman typically fell to Social Services, but in this case, the necessary documentation was not completed. The facility's Bed Hold Policy, dated March 9, 2019, requires that a Bed Hold Notice form be provided to the resident or their representative when a resident is transferred to a hospital or goes on therapeutic leave. However, this procedure was not followed for Resident #26, as acknowledged by the facility's Administrator.
Failure to Refer Residents for Level II PASRR Evaluation
Penalty
Summary
The facility failed to refer two residents for a Level II Preadmission Screening and Resident Review (PASRR) evaluation despite the presence of serious mental disorders. Resident #16 had a Minimum Data Set (MDS) assessment indicating severely impaired cognition and a diagnosis of schizophrenia, which was not included in the Level I PASRR screening. The facility's administrator acknowledged that the diagnosis of schizophrenia should have been identified and included in the PASRR since 2020. Additionally, the facility lacked a policy related to PASRR, relying instead on federal regulations. Resident #36's MDS assessment showed moderately impaired cognitive skills and diagnoses of anxiety disorder, psychotic disorder, and Parkinsonism. Despite these findings, the PASRR Level I Screen Outcome did not indicate a need for PASRR intervention. The resident's medical records revealed a diagnosis of unspecified psychosis not due to a substance or known physiological condition, which occurred during their stay. The Director of Nursing and Social Services Director confirmed that a new PASRR was not completed to reflect this additional diagnosis. The facility did not have a PASRR policy but stated they followed federal regulations.
Failure to Address Dementia Care in Resident's Care Plan
Penalty
Summary
The facility failed to address dementia care for a resident diagnosed with non-Alzheimer's dementia, stroke, seizure disorder, mild dementia without behavioral, psychotic or mood disturbance, and anxiety. The resident's Minimum Data Set (MDS) assessment indicated a Brief Interview for Mental Status (BIMS) score of 5, reflecting severely impaired cognition. Despite these diagnoses, the resident's care plan, revised on 10/21/24, lacked information regarding dementia care. The facility's Comprehensive Care Plan policy, revised on 7/18/22, mandates that care, treatment, and services be individualized to the resident's needs, including a comprehensive plan of care with measurable objectives and timetables. However, the facility did not adhere to this policy for the resident in question. During an interview, the Director of Nursing acknowledged that the facility should have addressed the resident's dementia in the care plan.
Infection Control Deficiencies in Medication and Personal Care
Penalty
Summary
The facility failed to adhere to proper infection prevention practices during medication administration, personal care, catheter care, and wound care for three residents. For Resident #22, a registered nurse was observed pouring medications directly from stock bottles into his bare hands before placing them into a medication cup, contrary to the facility's policy which requires using the cap of the stock medication or directly into the medication cup. This action was not in line with the expected infection control practices as outlined by the Director of Nursing (DON). Resident #58, who used a urinary indwelling catheter, received catheter care from a certified nursing assistant (CNA) who did not follow proper hand hygiene protocols. The CNA changed gloves multiple times without performing hand hygiene and failed to wear a gown as required by the facility's transmission-based precaution policy. The DON acknowledged these lapses in infection control, noting the absence of enhanced barrier precautions and the failure to perform hand hygiene before leaving the resident's room. For Resident #1, who had a new Stage II pressure ulcer, a licensed practical nurse (LPN) did not perform hand hygiene between glove changes during wound care. The LPN also failed to wear a gown, despite the presence of an enhanced barrier precaution sign outside the resident's room. The DON confirmed that staff should perform hand hygiene between glove changes and use enhanced barrier precautions when dealing with open wounds, indicating a breach in the facility's infection control protocols.
Failure to Provide Adequate Assistance During Repositioning
Penalty
Summary
The facility failed to prevent an accident involving a resident who required assistance with repositioning in bed. The resident, who had a care plan indicating the need for two staff members to assist with repositioning, was assisted by only one Certified Nursing Assistant (CNA) when she rolled out of bed and sustained injuries. The resident, who had a Brief Interview of Mental Status (BIMS) score of 14 indicating no cognitive impairment, suffered a closed displaced fracture of her left femoral neck, requiring surgical repair. The incident occurred when the resident requested to be repositioned in bed. Despite the care plan's requirement for two-person assistance, only one CNA was present to assist the resident. During the repositioning, the resident slipped off the grab bar and fell to the floor, resulting in significant injuries. The facility's investigation noted that the resident was too close to the edge of the air mattress, which may have shifted during the repositioning, contributing to the fall. Interviews with staff revealed that some were unaware of the care plan's requirement for two-person assistance, and others preferred to have additional help to prevent injury. The Director of Nursing acknowledged that the care plan required two staff members for repositioning and that the CNA should not have assisted the resident alone. The facility's policies on comprehensive care plans and ADL services were reviewed, highlighting the need for individualized care plans appropriate to residents' needs.
Failure to Follow Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to the care plan for a resident who required total assistance from two staff members for repositioning in bed. The resident, who had a BIMS score indicating no cognitive impairment, was diagnosed with spina bifida, seizure disorder, anxiety, opioid use, insomnia, and chronic pain syndrome. The care plan, revised in July 2024, specified the need for two staff members to assist with repositioning, utilizing bilateral grab bars. However, on a night in July 2024, the resident activated the call light for assistance, and a CNA responded alone, helping the resident roll to the right side. This action resulted in the resident being too close to the edge of the bed and subsequently falling onto the floor. The Director of Nursing acknowledged that the care plan required two staff members for repositioning, but the CNA involved was unaware of this requirement. The CNA stated that she had been informed that the resident required assistance from only one staff member. The facility's policy on comprehensive care plans, revised in July 2022, mandates individualized, interdisciplinary plans appropriate to each resident's needs. The failure to follow the care plan as documented led to the resident's fall, highlighting a breakdown in communication and adherence to established protocols.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat five residents with dignity and respect, as evidenced by multiple incidents involving improper handling and communication by staff. Resident #2, who had no cognitive impairment, reported being taken to the shower room in his underwear without any covering. This was corroborated by another resident who witnessed the incident and reported it to the Director of Nursing (DON). Despite the resident's military background and lack of personal discomfort, the DON acknowledged that such actions were inappropriate and assured it would not happen again. Resident #5, who also had no cognitive impairment and used a wheelchair, experienced neglect and rough handling by a staff member. The resident needed assistance to use the restroom and was denied the use of a mechanical lift, which he had been using for a year. The staff member shoved him back into his chair and told him to urinate in his pants, leading to the resident soiling himself. The DON confirmed that the staff member did not follow the facility's policy of having two staff members present when using a mechanical lift and that the lift was functional when checked by other staff. Resident #6, who had no cognitive impairment and used a wheelchair, was subjected to verbal mistreatment by a staff member who insisted she could not walk, despite the resident's protests and a sign indicating she required assistance with a gait belt. The resident felt helpless and worthless due to the staff member's behavior. Additionally, Resident #7 and Resident #8 were observed being transported to and from the shower room without proper covering, exposing their bodies inappropriately. The Assistant Director of Nursing (ADON) acknowledged ongoing issues with staff not adequately covering residents during transfers and emphasized the need for complete coverage with bath blankets.
Improper Transfer Procedures
Penalty
Summary
The facility failed to transfer two residents in a manner that prevented accidents and hazards. Resident #5, who had a BIMS score of 13 and used a wheelchair, was transferred using a mechanical lift by a single staff member, contrary to the facility's policy requiring two staff members. During one such transfer, the mechanical lift stopped working, and the resident was left in a recliner. The resident reported hitting his hands on the metal frame of the bathroom entrance during these transfers. Staff interviews confirmed that the policy was not followed, and the staff member involved was aware of the requirement for two staff members but chose to proceed alone due to difficulty finding assistance. The Director of Nursing (DON) and other staff members corroborated these findings, noting that the staff member had received training but failed to adhere to the policy consistently. The resident expressed distress over the incident, and the staff member was subsequently suspended for not following the policy. Another staff member also admitted to performing transfers alone when unable to find help, further highlighting the issue of non-compliance with the facility's policy. Resident #6, who had a BIMS score of 15 and used a wheelchair, was also not transferred according to the care plan. The care plan required two staff members to assist with transfers using a walker, but a staff member attempted to use a mechanical lift instead. The resident objected, stating she could walk short distances with a walker, but the staff member insisted on using the lift, leading to a confrontation. The resident felt helpless and worthless as a result of the incident. The DON and other staff members confirmed that the policy required two staff members for transfers and that the staff member involved had been educated on the proper procedures. Despite this, the staff member chose to use the lift alone, citing previous difficulties with the resident's mobility. The facility's policy, as outlined in the Lifting and Transferring Orientation Guide for Nurses and CNAs, mandates that all nursing staff be oriented to lifting and transferring techniques upon hire and that the use of any mechanical lift requires at least two staff members. The facility's failure to adhere to this policy resulted in improper transfers for both residents, leading to physical harm and emotional distress. Staff interviews and documentation revealed a pattern of non-compliance with the policy, despite repeated training and education efforts by the facility.
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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