Bettendorf Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Bettendorf, Iowa.
- Location
- 2730 Crow Creek Road, Bettendorf, Iowa 52722
- CMS Provider Number
- 165280
- Inspections on file
- 32
- Latest survey
- February 16, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Bettendorf Health Care Center during CMS and state inspections, most recent first.
The facility failed to ensure proper storage and documented disposition of discontinued and leftover medications after resident death or discharge. Staff reported that for two to three years, the DON kept discontinued medications in an unlocked cupboard in her office and stored discontinued narcotics in a locked desk drawer without inventory or shift-to-shift counts. Multiple staff, including an ADON, LPNs, and the HR Manager, observed 20–30 medications and narcotics in these locations, and the Administrator acknowledged that the DON had given a medication from this cupboard to a CNA. For three residents, the facility could not provide documentation that medications dispensed in blister-packs and other forms were either destroyed or returned to the pharmacy, despite policies requiring discontinued medications to be removed from active use, stored in a separate locked area, and destroyed or returned with proper documentation and witnesses.
A resident with complex medical and mental health needs was discharged after signing an AMA form without being adequately educated on discharge options or prepared for a safe transition. The resident, who required assistance with daily living and medication management, left for a homeless shelter without medications or a clear care plan, resulting in a subsequent hospitalization. Staff interviews confirmed that no alternative discharge plans were discussed and that the resident did not fully understand the AMA process.
The facility failed to provide scheduled bathing services to four residents, as per their care plans and preferences. One resident reported not being offered a bath or shower for over a week after refusing one due to feeling unwell. Another resident, preferring weekly showers, did not receive one for five weeks until she mentioned it to therapy staff. A third resident could not recall the last time he had a bath or shower, with no documentation since his recent hospitalization. A fourth resident, preferring bed baths twice weekly, reported inconsistencies in receiving them. The ADON acknowledged the issue and implemented changes to the staff assignment sheet.
The facility failed to maintain three shower rooms in a sanitary condition, with missing tiles, dirty grout, and residue buildup observed. Staff interviews revealed a lack of awareness and unclear responsibilities for cleaning and maintenance. The facility's policy on providing a safe and homelike environment was not followed, leading to unsanitary conditions.
The facility failed to respond to resident call lights within the expected timeframe, leading to a deficiency in meeting resident needs. A resident with intact cognition reported prolonged response times, and another resident with mild cognitive impairment experienced a delay of over 30 minutes in receiving assistance. Despite staff presence at the Nurses Station, call lights were not promptly addressed, highlighting a systemic issue in timely resident care.
A facility failed to consistently assess and monitor a resident's condition before and after dialysis treatments. Despite the resident's intact cognition and regular dialysis schedule, the care plan lacked specific interventions for pre- and post-dialysis assessments. Staff interviews and record reviews revealed inconsistent documentation practices, with only one post-dialysis assessment recorded in the previous month.
A resident with memory impairment and moderate decision-making impairment did not receive adequate nail care, resulting in long, thick, and yellow toenails. Despite family requests, no action was taken. Staff interviews revealed a lack of clarity on responsibilities for toenail care, compounded by the absence of a podiatrist since the previous one retired.
A resident with a history of dysphagia and a physician's order to eat under supervision was observed eating unsupervised in her room. Despite being on isolation due to MRSA, staff interviews and observations confirmed that the resident was left alone during meals, contrary to the care plan and physician's directives.
The facility failed to maintain proper catheter care for a resident, with observations showing the Foley catheter bag and tubing frequently touching the floor. Additionally, inadequate incontinent care was provided to another resident, with a CNA failing to cleanse necessary areas due to understaffing. Staff interviews confirmed expectations for proper care were not met.
The facility failed to prepare pureed food to the correct texture for two residents, as observed during a survey. The Dietary Manager confirmed the inconsistency, and staff reported previous complaints about the kitchen. The facility's policy on pureed food preparation was not followed, affecting residents with specific dietary needs due to conditions like dysphagia.
The facility was cited for repeated deficiencies in areas such as Activities of Daily Living, accident hazards, bowel/bladder incontinence, and sufficient nursing staff. Despite having a QAPI plan and monthly meetings to address issues, the facility failed to effectively correct these deficiencies, as evidenced by repeated citations in recent years.
A medication error occurred when a CMA mistakenly administered another resident's medications, leading to a significant adverse event. The resident, with a history of hypertension, renal insufficiency, and seizure disorder, received medications including Cefadroxil, L-Arginine, Trazodone, Tamsulosin, Baclofen, and Melatonin. This resulted in acute encephalopathy and hypotension, requiring intubation and ICU admission. The error was due to a failure in following medication administration protocols.
A facility failed to provide physical therapy services as per physician orders for a resident. The resident was supposed to receive therapy five times a week, but records showed they only received it once or twice during certain weeks. Despite progress noted by the PTA, the prescribed therapy frequency was not met, resulting in a deficiency.
Improper Storage and Undocumented Disposition of Discontinued Medications
Penalty
Summary
The deficiency involves the facility’s failure to properly dispose of or return discontinued, unused, or leftover medications following resident death, discharge, or changes in medication regimens. Surveyors found that for three residents, the facility could not provide documentation that medications were either destroyed or returned to the pharmacy as required by policy. The facility’s own self-reported incident indicated that an anonymous complaint to the corporate compliance office alleged theft of resident medications, and the subsequent internal investigation identified concerns with how discontinued medications were handled and stored. The facility had recently changed from one pharmacy provider to another, and medications were supplied both via an automated dispensing system and blister-pack cards, with narcotics stored under double lock in medication carts and other medications in a locked medication room. Interviews with multiple staff revealed that discontinued medications, including narcotics, were routinely stored in the DON’s office rather than being promptly destroyed or returned. The former ADON reported that when residents were discharged or had medication changes, the former DON placed these medications in an unlocked cupboard in her office, a practice that had been ongoing for two to three years. She stated there had been at least 30 medications in that cupboard and that the former DON said they might as well keep them since they would not receive pharmacy credit. The ADON and other staff reported that the former DON gave medications from this cupboard to staff who did not have insurance and discussed helping a family member with these medications. Staff also reported that discontinued narcotics were kept in a locked drawer of the DON’s desk without any inventory or shift-to-shift count, and that only the DON had the key until the HR Manager accessed the desk during the DON’s vacation and found multiple medications, including narcotics. The review of clinical records and pharmacy documentation for specific residents showed missing evidence of proper medication disposition. One resident who was admitted and later died at the facility had multiple medications dispensed in blister-pack form by both pharmacies, including atorvastatin, pantoprazole, warfarin, bumetanide, carvedilol, and hydroxyzine; the facility could not produce documentation of destruction or pharmacy invoices showing return of these medications after the resident’s death. Another resident who was admitted and later discharged had lidocaine 5% patches dispensed, but the facility could not provide documentation of destruction or return after discharge. A third resident, admitted and later discharged home, had several medications dispensed by the second pharmacy (bumetanide, glipizide, lisinopril, apixaban, and oxybutynin), and the facility could not provide pharmacy invoices documenting their return. Interviews with pharmacy representatives clarified that, contrary to some staff beliefs, blister-pack medications could be returned for credit under certain conditions, and facility policies required that discontinued medications be removed from active use, stored in a separate locked area, and either returned or destroyed with appropriate documentation and witnesses. These findings collectively demonstrate that the facility did not follow its own policies and applicable standards for the secure storage and disposition of discontinued and leftover medications. Additional staff interviews further detailed the inconsistent and improper handling of discontinued medications. One LPN stated that there was a tote in the medication room where discontinued medications were placed and that, because the pharmacy often refused returns, nurses used a Drug Buster system to destroy them. However, other staff consistently described the presence of approximately 20–30 discontinued medications in the DON’s office cupboard and narcotics in the DON’s desk drawer. The HR Manager confirmed that, during the DON’s vacation, he unlocked her desk to retrieve personnel paperwork and observed at least 20 different medications in the drawer, and he reported this to the Administrator. The Administrator acknowledged that the corporate investigation confirmed medications were stored inappropriately in an unlocked cupboard in the DON’s office and that the DON had given a CNA one of these medications, which the CNA later returned during the investigation. The Administrator also stated that narcotics found in the DON’s desk included a blister-pack card and a used bottle of liquid morphine with an unknown remaining amount, and that it was not appropriate for the DON to keep narcotics in her desk. Facility policies in effect required all drugs and biologicals to be stored in locked compartments, controlled substances to be secured under double lock, discontinued medications to be removed from active use and stored in a separate locked area, and all destruction or return of medications to be documented with appropriate witnesses, which did not occur in these instances. Pharmacy representatives provided additional context that contrasted with staff practices and beliefs. A nurse consultant from the second pharmacy stated that medications should be returned to the pharmacy when discontinued or when a resident is discharged, except for narcotics, topicals, inhalers, accessed vials, or other non-returnable items, and that returns had to occur within a specified time frame to receive credit. A representative from the first pharmacy stated that the state was a no-return state for credit, while another LTC pharmacist consultant clarified that facilities could return blister-pack medications for credit even if some doses had been used, as long as the remaining doses were sealed and intact, and that this was common practice in the state. These statements, combined with the facility’s inability to produce destruction logs or return invoices for the medications associated with the three residents, and the documented storage of discontinued medications and narcotics in the DON’s office and desk, form the basis of the deficiency related to failure to complete proper disposition of medications in accordance with policy and regulation.
Failure to Provide Adequate Discharge Planning and Education for Resident Leaving AMA
Penalty
Summary
The facility failed to ensure that a resident was adequately educated on potential discharge options and prepared for a safe transfer/discharge after the resident signed an Against Medical Advice (AMA) form. The resident, who was cognitively intact and had multiple medical diagnoses including heart failure, neurogenic bladder, diabetes mellitus, and persistent mood disorders, required assistance with several activities of daily living and was on a complex medication regimen. Despite these needs, there was no documentation that alternative discharge plans were discussed with the resident on the day of discharge, nor was there evidence that the resident was provided with sufficient information or support to ensure a safe transition. The incident began after an altercation between the resident and another resident, which resulted in both being sent to the hospital for evaluation. Upon return, the resident was presented with the AMA paperwork by the Business Office Manager (BOM) and Director of Nursing (DON), which he signed. Interviews revealed that the resident did not fully understand the AMA form and felt pressured to leave due to concerns about the incident and possible police involvement. Staff interviews confirmed that the resident needed facility-level care for his mental health and diabetes management, and that he was not offered other suitable discharge alternatives within the next 30 days. The resident ultimately left the facility for a homeless shelter, arranged by the social worker, without his medications and without a clear plan for ongoing care. He subsequently experienced a significant health issue related to his diabetes and required hospitalization. The facility did not have a policy regarding discharge against medical advice, and staff acknowledged that no comprehensive discharge planning or education was provided to the resident prior to his departure.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to provide adequate bathing and showering services to four residents, as per their care plans and preferences. Resident #2, who has intact cognition and requires substantial staff support for bathing, reported not being offered a bath or shower for over a week after refusing one due to feeling unwell. The facility's Shower Book lacked documentation of any completed showers or baths for this resident after the refusal. Resident #3, also with intact cognition and requiring moderate staff support, preferred weekly showers but reported not receiving one for five weeks until she mentioned it to therapy staff. The facility's Shower Book did not document any showers or baths for this resident, indicating a lack of adherence to her care plan. Resident #4, who requires substantial staff support, could not recall the last time he had a bath or shower, noting it was before his recent hospitalization. The facility's Shower Book confirmed no documentation of showers or baths since his return. Resident #5, who prefers bed baths twice weekly, reported inconsistencies in receiving them, with the last documented bed bath occurring on a different day than scheduled. The Assistant Director of Nursing acknowledged the issue and implemented changes to the staff assignment sheet to address the deficiency.
Deficiency in Shower Room Maintenance
Penalty
Summary
The facility failed to maintain three shower rooms in a functional and sanitary manner, as observed during a survey. The East Hall Shower Room had missing floor tiles and dirty grout, with a thick black residue along the floor and wall junctions. Staff A, a CNA, mentioned that the tiles had been missing for several months, and she believed the Housekeeping Department was responsible for cleaning the shower rooms. The Interim Administrator was unaware of the missing floor tiles and the condition of the grout and residue buildup. The [NAME] Hall Shower Room was observed to have a dark gray residue buildup on the grout between the tiles, with dirty caulk and orange calcium buildup along the floor and wall junctions. The discoloration and buildup extended up to eight inches high on the walls. The Interim Administrator stated she thought Housekeeping cleaned the tile floors but would check with Maintenance Staff regarding the grout cleaning responsibilities. The North Hall Shower Room had dirty grout with black residue buildup, missing wall tiles, and exposed crumbling structure. The black residue was present on the floor and walls, with several tiles not attached to the wall. The Interim Administrator mentioned that repairs were prioritized after the initial observation, but the report does not detail any corrective actions taken before the survey. The facility's policy on maintaining a safe and homelike environment was not adhered to, as evidenced by the unsanitary conditions in the shower rooms.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights within the expected timeframe, leading to a deficiency in meeting resident needs. Resident #2, who has intact cognition and requires substantial staff assistance for daily activities, reported that staff response times to call lights were typically 45 minutes or longer. This delay in response was consistent regardless of the time of day or week, indicating a systemic issue in addressing resident needs promptly. Additionally, an observation on a specific day revealed that Resident #9's call light remained activated for over 30 minutes without a response from staff, despite multiple staff members being present at the Nurses Station. Resident #9, who has mild cognitive impairment and requires assistance for transfers and toileting, activated the call light but did not receive timely assistance. The delay was attributed to the assigned CNA being on break, and other staff members did not respond to the call light promptly. The Director of Nursing and Interim Administrator acknowledged that any available staff should answer call lights, but this expectation was not met during the observed period.
Failure to Monitor Resident's Condition Before and After Dialysis
Penalty
Summary
The facility failed to provide ongoing assessments and monitoring of a resident's condition before and after dialysis treatments. The resident, who has intact cognition and is diagnosed with renal insufficiency, renal failure, and end-stage renal disease, receives hemodialysis three times a week. The care plan for the resident did not include specific interventions for staff to assess the resident's condition before and after dialysis treatments. Although the resident reported that a nurse assesses her condition before leaving for dialysis, the facility's documentation practices were inconsistent. Interviews with staff revealed that while training on port care and documentation is provided, the facility did not consistently document assessments after the resident returned from dialysis. The Director of Nursing confirmed that no assessment of the resident's condition is completed upon return from dialysis services. A review of the nurse progress notes showed only one entry related to post-dialysis assessment in the previous month, and the facility's dialysis communication and transfer documentation failed to include an assessment upon the resident's return.
Inadequate Nail Care for Resident with Memory Impairment
Penalty
Summary
The facility failed to provide adequate nail care for a resident with memory impairment and moderate decision-making impairment, who required substantial to maximum staff assistance for bathing and hygiene. The resident, diagnosed with non-Alzheimer's dementia and anxiety disorder, was observed with long, thick, and yellow toenails curling over the toes. The resident's family reported having requested nail care at least twice since the resident's admission, but no action had been taken. Interviews with staff revealed that Certified Nursing Assistants (CNAs) were responsible for cutting toenails unless the resident was diabetic, in which case nurses were responsible. The Director of Nursing (DON) mentioned that the facility's podiatrist had retired, and a new contract was being arranged, resulting in a lack of podiatrist visits since March or April. The facility's policy on Activities of Daily Living Care Bathing did not address toenail care, contributing to the oversight.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to follow a physician's order to ensure a resident ate meals in a safe manner. Resident #38, who has intact cognition and a history of cerebrovascular accident, seizure disorder, and dysphagia, was observed eating meals in her room without supervision, contrary to the physician's order that required her to eat upright in the dining room under supervision. The resident's care plan indicated a need for a mechanically altered diet due to dysphagia and required monitoring for signs of swallowing difficulties, but it did not specify supervision requirements when eating in her room. Observations revealed that Resident #38 was left unsupervised while eating in her room on multiple occasions. Staff interviews confirmed that the resident was on isolation due to MRSA in her sputum and was eating in her room, but staff were supposed to stay with her during meals. However, the resident reported that staff did not remain in the room while she ate, and observations corroborated this, showing no staff present during meal times in her room.
Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain proper catheter care for a resident identified as Resident #18, who was cognitively intact and dependent on staff for various activities. Observations revealed that the resident's Foley catheter bag and tubing were frequently found touching the floor, both in the resident's room and in common areas such as the dining room and hallway. Despite the facility's policy on catheter care, which did not specifically address keeping the catheter bag and tubing off the floor, staff interviews confirmed that the expectation was to keep the catheter bag below the waist, covered for dignity, and off the floor at all times. Additionally, the facility failed to provide adequate incontinent care for a resident identified as Resident #2, who had severe cognitive impairment and required substantial assistance for personal hygiene. During an observation, a CNA provided care without cleansing the perineal area, abdominal folds, or hips, despite the resident being incontinent. The CNA cited understaffing as a reason for inadequate care. Interviews with nursing staff, including the DON, indicated that the expectation was to thoroughly cleanse the perineal area and other affected areas using appropriate materials, as outlined in the facility's policy on incontinent care.
Failure to Prepare Pureed Food to Physician-Ordered Texture
Penalty
Summary
The facility failed to properly prepare pureed food according to physician-ordered texture for two residents on a pureed diet. During an observation, it was noted that the food served to these residents did not meet the required consistency. The pureed meat was observed to be thick and more like ground meat rather than smooth, as required. The Dietary Manager confirmed that the meat should have been smooth and the vegetables should have been like pudding. The State Agency intervened and requested the removal of the plates from the residents. The deficiency was further highlighted by staff interviews, where a Certified Nursing Assistant mentioned that several complaints had been made to the administrator about the kitchen, but no action had been taken. The facility's policy on pureed food guidelines, which directs staff to ensure food is prepared to a smooth consistency, was not followed. The residents involved had specific dietary orders due to their medical conditions, including dysphagia, which necessitated a pureed diet to ensure safe swallowing.
Repeated Deficiencies in Facility's QAPI and Staffing
Penalty
Summary
The facility failed to effectively correct deficiencies without repeated citation, as evidenced by the CMS CASPER reports. The deficiencies cited include F677 Activities of Daily Living in 2022 and 2023, F689 Free of Accident Hazards/Supervision/Devices in 2023, F690 Bowel/Bladder Incontinence, Catheter in 2023, F725 Sufficient Nursing Staff in 2020, 2022, and 2023, and F865 QAPI Program/Plan, Disclosure/Good Faith Attempt in 2023. These deficiencies were identified during the Recertification Survey with an exit date of August 15, 2024. During an interview, the Administrator explained that concerns are brought to the QA Committee through data from various sources, including input from employees, residents, families, audits, and grievances. This information is discussed in morning management meetings and referred to the QAPI committee when a problem is identified. The facility's QAPI Plan, dated August 20, 2020, outlines the purpose and procedures for quality assurance and performance improvement activities, but the repeated citations suggest that the measures taken were not effective in correcting the deficiencies.
Medication Error Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident received their ordered medications, resulting in a significant medication error. On the evening of June 3, 2024, a Certified Medication Aide (CMA) mistakenly delivered the wrong medications to a resident. The error occurred when the CMA, after completing his medication pass, assisted a Registered Nurse (RN) on another hall. The RN had set up medications for two residents in medication cups on the cart. The CMA, instructed by the RN, mistakenly took the wrong medication cup and administered it to the resident. Upon realizing the error, the RN notified the appropriate personnel, and the resident was sent to the emergency room for further evaluation. The resident, who had a history of hypertension, renal insufficiency, and a seizure disorder, experienced a significant change in condition due to the accidental overdose. The medications administered in error included Cefadroxil, L-Arginine, Trazodone, Tamsulosin, Baclofen, and Melatonin. The resident, who was on dialysis, developed acute encephalopathy and hypotension as a result of the overdose. In the emergency room, the resident became sedate, difficult to arouse, and required intubation to maintain her airway. She was subsequently admitted to the intensive care unit (ICU) for close monitoring and management. The incident highlighted the failure of the facility to adhere to medication administration protocols, specifically the requirement that the person who prepares the medication must be the one to administer it. The RN admitted to knowing that the CMA picked up the wrong medication cup but did not stop him. This oversight, combined with the lack of attention to detail, led to the resident receiving another resident's medications, resulting in a serious adverse event that required intensive medical intervention.
Failure to Provide Prescribed Physical Therapy Services
Penalty
Summary
The facility failed to provide rehabilitation services in accordance with physician orders for a resident. The clinical record review and staff interview revealed that the resident had a physician's order for a physical therapy evaluation and treatment, with a specified frequency of five times a week. However, the Physical Therapy Treatment Encounter Notes indicated that the resident received physical therapy services only once during two separate weeks in January and twice during a week in February. Despite the resident's progress noted by the Physical Therapy Assistant, the prescribed frequency of therapy sessions was not met, leading to a deficiency in the provision of specialized rehabilitative services as required by the physician's orders.
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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