Blackhawk Life Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake View, Iowa.
- Location
- 73 West 5th Street, Lake View, Iowa 51450
- CMS Provider Number
- 165499
- Inspections on file
- 19
- Latest survey
- October 14, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Blackhawk Life Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was administered two long-acting insulins and an incorrect dose of metformin after staff failed to reconcile hospital discharge orders and clarify duplicate insulin prescriptions. The errors led to multiple episodes of hypoglycemia, emergency interventions, and hospitalization, as staff did not follow established procedures for medication verification and order clarification.
A resident with diabetes and severe cognitive impairment experienced multiple episodes of severe hyperglycemia, with blood glucose readings far above physician-ordered parameters. Nursing staff failed to promptly notify the physician as required, often relying on faxed communication instead of direct calls, leading to delays in care and ultimately resulting in the resident's hospitalization for severe hyperglycemia. Documentation showed gaps in follow-up and confusion among staff regarding emergency notification protocols.
A resident with Parkinson's Disease and moderate cognitive deficits, who was dependent on staff for transfers, was assisted by only one CNA instead of the required two during a toilet transfer. The resident lost balance and sustained an ankle injury, leading to increased transfer assistance needs. Staff interviews revealed gaps in orientation and communication regarding the resident's care plan.
A resident with no cognitive impairment and a history of respiratory and chronic lung conditions was not allowed to assist with the application of his prescribed leg compression devices, despite being capable and knowledgeable. A nurse insisted on performing the task without the resident's participation, disregarding his attempts to ensure proper fit, which led the resident to feel disrespected and file a grievance. This action failed to honor the resident's right to dignity and self-determination as outlined in facility policy.
A resident with chronic lung disease and no cognitive impairment did not have accurate documentation of Albuterol inhaler administration on the MAR for nearly two weeks. Staff were unable to locate the inhaler when requested, and when it was found, it was a different color but the same medication and dose. The LPN did not document administration as required by facility policy.
A resident with severe cognitive impairment and dysphagia, who required a pureed diet and close supervision, experienced repeated episodes of pocketing food and coughing during meals. Despite staff reporting these issues, nursing staff did not consistently assess or notify a physician about the resident's changes in condition. The resident's condition worsened over several weeks, ultimately resulting in hospitalization for aspiration pneumonia after consuming food of inappropriate consistency.
A resident with severe cognitive impairment and a history of falls did not consistently have her walker within reach as directed by her care plan, and staff were unclear about proper procedures. The resident also experienced a fall while not wearing a gait belt, despite this being a required intervention. These lapses resulted in inadequate supervision and failure to prevent accidents.
The facility failed to ensure proper glove use by dietary staff during meal service. A Dietary Aide was observed wearing gloves while touching various surfaces and then directly handling food without changing gloves. The Dietary Manager noted that staff were instructed to use gloves only when handling food directly, but glove use remained a challenge. The facility's policy requires changing gloves and washing hands between tasks.
A resident with severe cognitive deficit was found with bruising, which the facility attributed to a prior incident with a mechanical lift. However, the facility failed to conduct a thorough investigation or document a nursing assessment following the incident, violating their policy on investigating accidents and incidents.
A resident with severe cognitive deficits experienced a near miss incident with an EZ Stand lift, where the sling unhooked during a transfer. A CNA caught the resident, preventing a fall but injuring her back. The incident was not documented in nursing notes or reported, contrary to facility policy. The resident was not assessed immediately after the incident, and the event was not recorded in the electronic chart.
A resident with moderate cognitive impairment and a history of chronic heart failure experienced inadequate infection control practices during wound care. A nurse placed supplies without a barrier, failed to perform hand hygiene after removing gloves, and left a used dressing on the floor. The resident's slipper was wet from wound drainage and not changed. The DON was unaware of double gloving, and the facility's policy required hand hygiene after handling used dressings.
A resident with severe cognitive deficits slid from a mechanical lift when the sling hook disengaged, but no nursing assessment was conducted, and the incident was not reported. Despite the resident's agitation and the potential for injury, staff were incorrectly informed that an incident report was unnecessary. The facility's policy requiring assessment and documentation after such incidents was not followed.
Two residents experienced unsafe transfers with mechanical lifts due to staff errors and inadequate safety measures. One resident was injured by a Hoyer lift during a transfer, while another had a near miss with an EZ Stand lift. The facility failed to follow proper procedures and documentation, contributing to these incidents.
The facility failed to immediately report allegations of abuse for two residents. One resident was slapped and manhandled by a CNA, and another resident was tapped hard by the same CNA in a separate incident. Both incidents were not reported to the administration or state authorities immediately, resulting in Immediate Jeopardy to the residents' safety.
The facility failed to immediately separate an alleged abuser from residents, resulting in potential harm to two residents. A CNA reported that another CNA slapped a resident, but did not intervene or report the incident immediately. Another staff member reported a similar incident involving the same alleged abuser, which was also not reported to the administration. This failure to follow reporting procedures created an immediate jeopardy situation for the residents.
The facility failed to treat residents with dignity and respect, as evidenced by two residents waiting over an hour for their meals and another resident reporting rude behavior from a staff member. Residents requiring assistance with eating and transfers experienced significant delays, and one resident was embarrassed by a nurse when inquiring about her medication.
The facility failed to assist residents with ADLs, resulting in significant delays in meal service for three residents and missed scheduled baths for two residents. Staff indicated the lack of specific policies and reliance on individualized care plans contributed to these deficiencies.
The facility failed to ensure the safety of residents during mechanical lift transfers, resulting in an incident where a lift tipped over while transferring a resident. Staff reported prior issues with the lift's functionality, which were not adequately addressed. Additionally, the facility used inappropriate slings and failed to properly secure them during transfers, compromising resident safety.
A resident fell from a mechanical lift during a transfer, but the facility failed to notify the family and doctor as required by policy. The resident, who was on hospice care and had multiple diagnoses, was uninjured, leading staff to believe notifications were unnecessary. The Administrator confirmed no incident report was completed for the resident.
A resident with severe cognitive deficits was subjected to unnecessary punishment and abuse by a CNA, who slapped her, stepped on her foot, and forcefully placed her into a wheelchair. The incident was not immediately reported, and the resident's condition was not assessed until days later.
The facility failed to update and follow the Care Plan for a resident with severely impaired cognition who frequently hit and scratched staff. Despite multiple incidents and staff injuries, the facility did not monitor or document the underlying causes of the resident's behaviors as directed by the Care Plan.
The facility failed to provide timely assessments and interventions for two residents. One resident fell during a transfer with a mechanical lift, and the nurses did not perform a full assessment afterward. Another resident with severe dementia exhibited aggressive behaviors, and the staff did not monitor or document the effectiveness of interventions. The facility did not follow its policies on Care Plan Development and Fall Protocol.
The facility failed to implement incident reports and investigations for three residents. A resident experienced a mechanical lift tipping over, another sustained a skin tear, and a third had scratches on her arms, but no incident reports or investigations were conducted. The facility did not hold formal interdisciplinary team meetings to address these issues.
Failure to Prevent Significant Medication Errors Following Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors during and after a hospitalization for hyperglycemia. Upon the resident's return from the hospital, staff did not properly reconcile the medication list, resulting in the administration of two long-acting insulins (Tresiba and Lantus) and an incorrect dose of metformin. The hospital discharge summary specified that the resident should receive Lantus 20 units daily and metformin 500 mg twice daily, but the facility staff administered both Lantus and Tresiba, as well as 1000 mg of metformin instead of the prescribed 500 mg dose. The resident, who had a severe cognitive deficit and required assistance with daily activities, was unable to understand or communicate her diabetes diagnosis and symptoms. Staff failed to clarify duplicate insulin orders with the provider, despite recognizing that both insulins were long-acting and that the resident had not previously been on insulin before hospitalization. The error was compounded by a lack of communication and verification among nursing staff, with the LPN administering both insulins after discussing the orders with the ADON, who advised consulting the DON. The DON did not provide clarification before the medications were given, and the error was only discovered after the resident exhibited symptoms of hypoglycemia. As a result of these medication errors, the resident experienced multiple episodes of low blood glucose, including readings as low as 35 mg/dL, and required emergency interventions such as administration of glucagon and transfer to the hospital. The facility's policies required staff to clarify any conflicting or questionable orders with the physician and to immediately remove discontinued medications from the medication cart, but these procedures were not followed, directly leading to the significant medication errors and the resident's subsequent hospitalization.
Failure to Notify Physician of Critical Blood Glucose Levels
Penalty
Summary
The facility failed to follow physician directives regarding blood glucose (BG) monitoring and notification for a resident with diabetes mellitus and severe cognitive impairment. The resident had orders to notify the physician if BG levels were less than 60 or greater than 400. Despite multiple BG readings significantly above 400, documentation shows that staff often faxed notifications to the provider rather than calling, resulting in delayed communication. There were also extended periods without documented follow-up or action after high BG readings, including intervals of over 12 hours between checks and notifications. The resident experienced repeated episodes of severe hyperglycemia, with BG values as high as 590, and exhibited symptoms such as confusion, lethargy, and weakness. Staff interviews revealed confusion about notification protocols, especially during weekends and after hours, with some nurses unsure of which provider to contact or relying on fax rather than direct communication. The nurse practitioner confirmed that faxes sent over the weekend were not received until the following week, and expected that nurses would call the on-call doctor for BG levels outside parameters. Clinical records and staff statements indicate that the lack of timely physician notification and follow-up contributed to the resident's deterioration, ultimately resulting in hospitalization for severe hyperglycemia. The documentation also showed that staff were not consistently oriented to emergency notification procedures, and there was a lack of immediate action in response to critical BG values as required by the physician's orders.
Failure to Follow Safe Transfer Protocols Results in Resident Injury
Penalty
Summary
The facility failed to ensure staff used safe transfer techniques for a resident who required assistance from two staff members for transfers, as documented in her care plan and Kardex. The resident, who had moderate cognitive deficits, Parkinson's Disease, and was totally dependent on staff for toileting and transfers, was assisted by only one staff member when getting off the toilet. During this transfer, the resident lost her balance, her foot slipped, and she was lowered to the floor, resulting in a twisted and swollen ankle with significant bruising and pain. The incident report and staff interviews confirmed that the agency staff member did not follow the care plan instructions requiring two-person assistance for transfers. Prior to the incident, the resident was able to ambulate with two staff, a gait belt, and a walker, but after the injury, she required the use of a standing mechanical lift for all transfers. Staff interviews revealed a lack of orientation and communication regarding the resident's transfer needs, with one CNA stating she was unaware of the requirement for two-person assistance and had not received a report from the previous shift. The facility's policy required interventions to be resident-specific and based on assessment findings, but these were not followed in this case, leading to the resident's injury.
Resident Not Allowed to Participate in Own Care During Compression Device Application
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had a history of acute respiratory failure with hypoxia and chronic lung disease, was not treated with dignity and respect while attempting to participate in his own care. The resident had an order for leg compression devices to be applied twice daily, which he was capable of applying himself. During one incident, a registered nurse applied the devices but did not allow the resident to assist, despite his knowledge and ability. The resident attempted to adjust the fit of the device to ensure it was snug, as required for effectiveness, but the nurse scowled at him and told him not to help, insisting that she was responsible for the task. The resident reported feeling dismissed and not allowed to participate in his care, which led him to file a grievance regarding the nurse's behavior. Staff interviews confirmed that the resident was generally able to apply the devices himself and that he should have been permitted to participate. The facility's own policies and the resident's rights documentation emphasized the importance of treating residents with dignity, respect, and allowing them to participate in their treatment, which was not upheld in this instance.
Failure to Accurately Document Medication Administration
Penalty
Summary
The facility failed to maintain an accurate record of medication administration for one resident. The resident, who had no cognitive impairment and diagnoses including acute respiratory failure with hypoxia and chronic lung disease, had a physician's order for an Albuterol inhaler to be administered as needed for wheezing. Review of the Medication Administration Record (MAR) for April showed a lack of documentation that the resident received the inhaler from April 1st to April 13th, despite the order being in place. Staff interviews revealed that on at least one occasion, the resident requested the inhaler, but it could not be located by the staff at that time. The inhaler was eventually found, but it was a different color than the one the resident had previously used, though it was the same medication and dose. Staff involved did not document the administration of the inhaler on the MAR for the night it was given or for a night or two prior, as required by facility policy. The policy stated that the individual administering the medication must record the administration on the MAR immediately after giving the dose. The lack of documentation and the confusion regarding the location and identity of the inhaler led to the deficiency cited by surveyors.
Failure to Assess and Intervene for Change in Condition Related to Swallowing Difficulties
Penalty
Summary
A resident with Alzheimer's disease, severe cognitive impairment, and dysphagia was identified as being at risk for weight change and aspiration due to altered nutrition intake and swallowing difficulties. The care plan specified a pureed diet with thin liquids, close supervision during meals, and specific swallowing strategies. Despite these interventions, there were multiple documented incidents where the resident was found pocketing food, coughing during meals, and consuming food of inappropriate consistency, including an episode where whole kernels of corn were removed from his mouth. Staff interviews revealed that several CNAs observed ongoing issues with the resident's eating and swallowing, including frequent coughing and pocketing of food, and reported these concerns to nursing staff. There was a lack of timely and adequate assessment and intervention by nursing staff in response to the resident's change in condition. Progress notes and staff interviews indicated that nurses did not consistently assess the resident or notify the physician when changes were observed, such as when the resident was found with regular food in his mouth or when he exhibited increased coughing and difficulty swallowing. Staff also reported that their concerns were not always acknowledged or acted upon by nurses, and that the resident's condition deteriorated over a period of weeks, culminating in an acute episode of labored breathing, hypoxia, and fever. The resident was eventually hospitalized with aspiration pneumonia after being found with low oxygen saturation, fever, and lethargy. Medical records indicated that the resident had likely aspirated food of a different consistency, leading to pneumonia. The lack of prompt assessment and intervention following observed changes in the resident's eating and swallowing behavior contributed to the development of this serious condition.
Failure to Implement Fall Prevention Interventions for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement and maintain appropriate fall prevention interventions for a resident with severe cognitive impairment and a history of repeated falls. The resident required assistance with transfers and ambulation, and her care plan included the use of a gait belt for all transfers, a walker within reach for safety, and chair and bed alarms. However, observations revealed that the resident's walker was frequently not within her reach, contrary to the care plan directives. Staff interviews indicated confusion and conflicting instructions from management regarding whether the walker should be left within the resident's reach, with some staff stating they were told not to do so. Additionally, documentation showed that during a witnessed fall, the resident was ambulating with her walker but did not have a gait belt on as required by her care plan. The resident's diagnoses included hypertensive chronic kidney disease, atrial fibrillation, diabetes, and depression, all of which increased her risk for falls and injury. The lack of adherence to the care plan interventions, including the absence of the gait belt and the walker not being within reach, directly contributed to the failure to prevent accidents and ensure adequate supervision.
Improper Glove Use by Dietary Staff
Penalty
Summary
The facility failed to ensure proper glove use by dietary staff during meal service, as observed during a lunch service. A Dietary Aide, identified as Staff H, was seen wearing disposable gloves while touching various surfaces such as counters, carts, and utensils. Without changing gloves, Staff H then handled food directly by reaching into a bread bag, pulling out six pieces of bread, buttering them, placing them on a plate, and covering them with wrap. The gloves were only disposed of after these tasks were completed. The Dietary Manager acknowledged that staff were instructed to use gloves only when handling food directly, but noted that glove use was challenging as staff often felt they could touch any surface with gloves on and then handle food. The facility's undated Glove Use Policy requires staff to follow hand washing guidelines, change gloves, and wash hands between potential contaminations and before starting new tasks.
Failure to Investigate Resident Bruising
Penalty
Summary
The facility failed to investigate new bruising on a resident, identified as Resident #25, who was reviewed for accidents. Resident #25, who had a severe cognitive deficit and required assistance with transfers, was found with bruising on her left rib cage and hand on 10/1/24. The administration attributed the bruising to an incident with the EZ stand mechanical lift on 9/7/24, where the resident had a near miss fall. However, there was no documented nursing assessment following the incident, and the facility did not conduct a thorough investigation into the cause of the bruising. The facility's policy requires that all accidents or incidents involving a resident be investigated, but in this case, the investigation was insufficient. Although staff interviews were conducted when the bruising was found, there was no documentation of these interviews, and no further investigation was pursued. The facility's failure to properly investigate the bruising, which could indicate abuse, was a deficiency in their compliance with their own policies and procedures.
Failure to Document and Report Resident Incident
Penalty
Summary
The facility failed to maintain accurate and timely records for Resident #25, who experienced a near miss incident involving an EZ Stand mechanical lift. During a transfer, the loop on the sling unhooked, causing the resident to swing to the left. A CNA caught the resident, preventing a fall, but injured her back in the process. Despite the incident, no incident report was completed, and the event was not documented in the nursing notes. The charge nurse was informed but did not consider it necessary to fill out an incident report since it was not classified as a fall. Resident #25, who has a severe cognitive deficit and requires assistance with transfers, was not assessed following the incident. The nursing notes for the night of the incident did not mention the event, and the electronic chart lacked any assessments for that day. The facility's policy requires that all accidents or incidents involving a resident be investigated and documented, but this protocol was not followed. The Administrator and DON later confirmed that an assessment was conducted two days after the incident, with no injuries noted, but acknowledged that the nurse should have completed an incident report and a nursing progress note at the time of the incident.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for a resident with a skin tear and cellulitis on the right lower leg. The resident, who had moderate cognitive impairment and was dependent on staff for lower body dressing, had a history of chronic heart failure and swelling in the lower legs. The care plan included interventions for skin integrity and cellulitis treatment. However, during an observation, a registered nurse placed treatment supplies on the resident's tray table without a barrier, did not perform hand hygiene after removing gloves, and left a used dressing on the floor. Additionally, the resident's slipper was wet from wound drainage, and the nurse did not change it. The Director of Nursing was unaware of the double gloving practice and stated that gloves should be changed and hands washed when soiled. The facility's handwashing and glove use policy required hand hygiene after handling used dressings and contaminated equipment. The report highlights the failure to adhere to infection control protocols, including the improper handling of wound care supplies and inadequate hand hygiene, which could potentially compromise the resident's health and safety.
Failure to Assess Resident After Mechanical Lift Incident
Penalty
Summary
The facility failed to ensure that staff assessed a resident after an incident involving the EZ Stand mechanical lift. Resident #25, who has a severe cognitive deficit and requires assistance with transfers, slid from the lift when the sling hook disengaged. Despite the incident, there was no nursing assessment documented in the resident's chart, and the incident was not reported as required. The resident's care plan indicated the need for staff to observe for signs of bruising due to antiplatelet medication, but no assessment was conducted following the incident. Staff involved in the incident reported that the resident was agitated and shaking the machine, which led to the sling unhooking. Although the CNAs reported the incident to the nurse on duty, they were incorrectly informed that an incident report was unnecessary since the resident did not fall to the floor. The nurse on duty did not perform an assessment or complete an incident report, as she believed the resident was unharmed. The facility's policy requires a full assessment and documentation following any accident or change in condition, which was not adhered to in this case.
Deficiencies in Safe Transfer Practices with Mechanical Lifts
Penalty
Summary
The facility failed to safely transfer residents using mechanical lifts, resulting in incidents involving two residents. Resident #10, who had severe cognitive impairment and was non-ambulatory, was injured during a transfer with a Hoyer lift. The incident occurred when the lift's leg got stuck under the wheelchair, and as staff attempted to pull the lift back, the sling bar swung and hit the resident on the head, causing a hematoma and bruising. Staff involved in the transfer did not adequately stabilize the lift arm, leading to the accident. Resident #25, who also had severe cognitive impairment and required assistance with transfers, experienced a near miss with an EZ Stand lift. During a transfer, the resident became agitated and began shaking the machine, causing a loop on the sling to disengage. The resident slid to the side, but staff managed to catch her and prevent a fall. Despite the incident, no incident report was filed because the resident did not hit the floor, and there was a lack of proper documentation and assessment following the event. The facility's policies on the use of mechanical lifts and incident reporting were not adequately followed, contributing to the deficiencies. The staff did not ensure that all safety measures were in place during transfers, and there was a failure to document and assess incidents properly. These lapses in procedure and communication led to unsafe conditions for the residents involved.
Failure to Report Allegations of Abuse Immediately
Penalty
Summary
The facility failed to immediately report allegations of abuse to the proper authorities for two residents. On the overnight shift, a CNA reported that Resident #2 hit, kicked, and spit at the staff. Another CNA, Staff F, then slapped Resident #2 on the face, stepped on her foot, and manhandled her into a wheelchair. Staff G, who witnessed the incident, did not report the alleged abuse to the administration until later in the morning. Resident #2, who has severe cognitive deficits and requires significant assistance with daily activities, did not show any new skin injuries upon assessment, but the incident was not reported immediately as required by policy. During the investigation, it was revealed that Staff P, an RN, had a similar situation with Staff F approximately three months prior. Staff F had admitted to Staff P that he tapped Resident #15 a little hard when she became combative. Staff P did not report this incident to the administration or state authorities. Resident #15, who also has severe cognitive impairments and requires total assistance for certain activities, did not exhibit physical behavioral symptoms during the week-long look-back period but had a history of verbal outbursts. The failure to report these incidents immediately resulted in an Immediate Jeopardy to the health, safety, and security of the residents. The facility's policy requires that all allegations of abuse be reported immediately to the charge nurse, who is then responsible for reporting to the administration. However, both Staff G and Staff P failed to follow this protocol, leading to a delay in addressing the abusive behavior of Staff F and ensuring the safety of the residents involved.
Removal Plan
- The facility administration separated the alleged perpetrator immediately upon notification from the staff of the incident. The alleged perpetrator was immediately suspended, and furthermore terminated upon the outcome of investigation.
- The facility added a Report Abuse Fact Sheet to the inside cover of the staff communication book as a permanent reference for all staff. In addition, they placed the Report Abuse Fact Sheets in the employee clock area, breakroom, as well as added to the new hire onboarding packets.
- The facility educated the staff on the process of reporting allegations of abuse. The facility staff will complete the IHCA (Iowa HealthCare Association) training: Understanding and Responding to Dementia Related Behaviors.
- The facility would review the Abuse policy at in services, and department meetings. In addition, they will review the policy with new employee onboarding. The facility will randomly audit staff on the facility process of reporting allegations of abuse. The facility will report the outcome of the audits to the QAPI (Quality Assurance Performance Improvement) interdisciplinary team. The QAPI team will establish any further direction on auditing this area based on outcomes.
Failure to Separate Alleged Abuser from Residents
Penalty
Summary
The facility failed to immediately separate an alleged abuser from residents, resulting in potential harm to two residents. On one occasion, a CNA reported that another CNA slapped a resident who was being combative. The reporting CNA did not intervene to prevent further harm and delayed reporting the incident until several hours after the shift ended, allowing the alleged abuser to continue working with other residents. This delay in reporting and failure to separate the alleged abuser from residents created an immediate jeopardy situation for the health, safety, and security of the residents. During the investigation of the incident, another staff member reported a similar situation involving the same alleged abuser. Approximately three months prior, the alleged abuser admitted to tapping another resident a little hard while trying to get her dressed for bed when she was combative. The staff member who received this information did not report it to the administration or separate the alleged abuser from residents, allowing the potential for further incidents to occur. The facility's failure to report and investigate these incidents promptly resulted in a lack of immediate action to protect the residents. The facility's policies and procedures for reporting abuse were not followed, leading to a delay in addressing the alleged abuse and preventing additional harm to the residents involved.
Removal Plan
- The facility administration separated the alleged perpetrator immediately upon notification from the staff of the incident. The alleged perpetrator was immediately suspended, and furthermore terminated upon the outcome of investigation.
- The facility added a Report Abuse Fact Sheet to the inside cover of the staff communication book as a permanent reference for all staff. In addition, they placed the Report Abuse Fact Sheets in the employee clock area, breakroom, as well as added to the new hire onboarding packets.
- The facility educated the staff on the process of reporting allegations of abuse. The facility staff will complete the IHCA (Iowa HealthCare Association) training: Understanding and Responding to Dementia Related Behaviors.
- The facility would review the Abuse policy at in services, and department meetings. In addition, they will review the policy with new employee onboarding. The facility will randomly audit staff on the facility process of reporting allegations of abuse. The facility will report the outcome of the audits to the QAPI (Quality Assurance Performance Improvement) interdisciplinary team. The QAPI team will establish any further direction on auditing this area, based on outcomes.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat residents with dignity and respect, as evidenced by multiple observations and resident reports. Residents #11 and #8 were observed sitting at the breakfast table for over an hour without being served their meals, while other residents had already finished eating. Resident #8, who has severe cognitive impairment and requires assistance with eating, spilled her drink on herself and the floor while waiting. Staff indicated that they could not serve these residents until an aide was available to assist them, leading to significant delays in their meal service. Additionally, Resident #10 reported that residents requiring assistance with transfers often had to wait until after 8:00 PM for help, and she also experienced rude and embarrassing behavior from a staff member when inquiring about her medication. Resident #11 has severe cognitive deficits and requires maximum assistance with eating and dressing, as well as total assistance with hygiene and transfers. His care plan includes a mechanically altered diet and assistance with eating. Resident #8 also has severe cognitive impairment and requires supervision and assistance with eating, as well as total assistance with hygiene and transfers. Her care plan includes a mechanically altered diet and monitoring for chewing and swallowing issues. Despite these care plans, both residents were left waiting for extended periods without receiving their meals. Resident #10, who is cognitively intact, observed these delays and reported feeling sorry for the affected residents. She also experienced a personal incident where a nurse embarrassed her in front of her roommate while discussing her medication.
Failure to Assist Residents with ADLs and Provide Scheduled Baths
Penalty
Summary
The facility failed to ensure residents received assistance with Activities of Daily Living (ADL) for five residents. During meal observations, three residents who required assistance with eating had to wait over an hour after other residents finished their breakfast to receive their meals. Specifically, Residents #8 and #11 were observed waiting for food and assistance from 8:10 AM to 9:26 AM, while Resident #14's family had to assist her with eating when they discovered she had not eaten yet. Staff indicated that residents with pureed food orders could not be served until an aide was available to assist them, leading to significant delays in meal service for these residents. Additionally, the facility failed to provide baths for two residents as directed by their care plans. Resident #1, who required total assistance with hygiene and bathing, only received three showers in a 30-day timeframe, despite her care plan indicating she should have a bath once a week. Similarly, Resident #13, who required partial assistance with baths and showers, only received two baths in the same period, even though he preferred to bathe once a week. Both residents missed their scheduled baths because the bath aide left early, and no alternative arrangements were made to offer them another opportunity for bathing. Interviews with staff revealed that the facility did not have specific policies related to feeding assistance or offering baths and showers, relying instead on individualized care plans. The Director of Nursing (DON) and other staff acknowledged the challenges in completing the bath list on scheduled days and the lack of a system to ensure residents received their baths if missed. The Administrator confirmed the absence of formal policies and the reliance on care plans to address residents' needs, contributing to the deficiencies observed in the care provided to these residents.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure the safety of residents during mechanical lift transfers, resulting in an incident where a mechanical full-body lift tipped over while transferring a resident. Resident #12, who required total assistance for transfers due to multiple health conditions, was being moved from his bed to a recliner when the lift tipped over. The staff managed to position the recliner to catch the resident, preventing injury, but the incident highlighted issues with the mechanical lift's maintenance and functionality. Staff reported that the lift had been unsteady and malfunctioning prior to the incident, with concerns about the legs not opening properly and the machine being difficult to steer. Despite these concerns being communicated to the maintenance staff, the issues were not adequately addressed, leading to the lift tipping over during the transfer. The maintenance staff admitted to not having a detailed maintenance schedule and only performing basic monthly checks, which were insufficient to identify and rectify the problems with the lift. Additionally, the facility used slings from a different manufacturer than the lift, which were not recommended by the lift's manufacturer, further compromising the safety of the transfers. Observations revealed that the staff failed to properly tighten the slings during transfers, causing residents to be inadequately supported and increasing the risk of accidents. This was evident in the transfers of Resident #5 and Resident #9, where the slings were not properly secured, and the residents were not adequately supported during the transfers. The facility's failure to ensure proper maintenance of the mechanical lifts and the use of appropriate slings directly contributed to the unsafe conditions during resident transfers.
Failure to Notify Family and Doctor After Resident Fall
Penalty
Summary
The facility failed to notify the family and the doctor after a resident fell from a mechanical lift. During a transfer from the bed to a recliner, the lift tipped over, causing the resident to fall into the recliner. Despite the incident, the staff did not call the family or the doctor, as they believed the resident was uninjured and capable of making his own decisions. The incident involved multiple staff members, and two staff members were injured during the event, leading them to complete employee incident reports. However, no incident report was completed for the resident, and no notifications were made to the family or the doctor. The resident involved had a BIMS score indicating intact cognition and required extensive assistance for various activities of daily living. He was on hospice care and had multiple diagnoses, including heart failure, renal insufficiency, diabetes, and morbid obesity. The facility's policy required notifying the physician and family in the event of an incident, but this protocol was not followed. The Administrator confirmed that no incident report was completed for the resident because he was not hurt, and no notifications were made to the family or the doctor.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from unnecessary punishment and abuse. On one occasion, a CNA reported that while assisting a resident to the toilet, the resident became aggressive, kicking, slapping, and spitting at the staff. In response, another CNA slapped the resident on the face, stepped on her foot, and forcefully placed her into a wheelchair. The resident, who had severe cognitive deficits and a history of behavioral problems, was left with a red mark on her cheek that disappeared by morning. The incident was not immediately reported to the nurse on duty, and the resident's condition was not assessed until days later. The resident involved had a history of Alzheimer's disease, vascular dementia, malnutrition, and anxiety disorder. She required total assistance for most activities of daily living and had frequent episodes of incontinence. The care plan for the resident included various interventions to manage her behaviors and ensure her safety, such as the use of anti-roll back brakes on her wheelchair, a pull alarm, and a Wander Guard alarm. Despite these measures, the resident exhibited aggressive behavior during the incident, which was not effectively managed by the staff. The facility's investigation revealed that the CNA involved in the incident had a history of losing his temper with residents and had previously been reported for similar behavior. The nurse on duty during the incident was unaware of the abuse until days later and did not assess the resident's condition immediately after the event. The facility's policy on abuse prevention and reporting was not followed, as the incident was not reported immediately, and the alleged abuser was not separated from the residents. The facility's administration was only made aware of the incident after it was reported by another staff member.
Failure to Update and Follow Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to update a Care Plan with resident-specific goals and interventions and did not follow the established interventions for a resident with severely impaired cognition. Despite staff reports of the resident often hitting and scratching them during care, the facility did not monitor these episodes to determine underlying causes as directed by the Care Plan. The resident's Minimum Data Set (MDS) assessment indicated severely impaired cognition and required varying levels of assistance for daily activities. The Care Plan included a focus on the resident's impaired cognitive function and risk for behaviors related to dementia, with interventions to monitor behavior episodes and document potential causes. However, these interventions were not followed, and the Care Plan was not updated accordingly. Staff interviews revealed that the resident frequently hit and scratched staff, causing injuries, and staff felt that better plans were needed to manage the resident's agitation. Nursing notes documented multiple incidents of the resident becoming combative and scratching staff over several months. The Director of Nursing and the Administrator acknowledged that they did not use incident reports to track and monitor these events, and Care Conferences did not include comprehensive discussions or solutions for the resident's behaviors. The facility's Care Plan Development policy required periodic review and updates, but this was not adhered to in the case of this resident.
Failure to Provide Timely Assessments and Interventions
Penalty
Summary
The facility failed to provide timely assessments and interventions for two residents. Resident #12, who had a history of heart failure, renal insufficiency, diabetes, and morbid obesity, fell when a mechanical lift tipped over during a transfer. Despite the incident, the nurses did not perform a full assessment on Resident #12 to check for injuries or pain, even though the resident was on hospice care and had significant health issues. The staff involved in the incident did not document a comprehensive follow-up assessment, and the Administrator was unaware if such an assessment had been completed. Resident #17, who had severe cognitive impairment due to dementia, exhibited aggressive and combative behaviors, including hitting and scratching staff. The facility staff failed to monitor and document the effectiveness of interventions to manage these behaviors. Despite multiple incidents of aggression, there were no formal Interdisciplinary Team Meetings to discuss root causes or potential solutions. The Care Plan for Resident #17 lacked detailed interventions and documentation of behavior episodes, and the facility did not use incident reports to track these episodes. The facility's policies on Care Plan Development and Fall Protocol were not followed. The Care Plan Development policy required periodic reviews and updates, which were not adequately performed for Resident #17. The Fall Protocol policy mandated immediate and continuous monitoring of a resident's physical and mental status after a fall, which was not done for Resident #12. The facility's Quality Assurance Performance Improvement policy aimed to provide excellent quality care, but the deficiencies observed indicate a failure to meet these standards.
Failure to Implement Incident Reports and Investigations
Penalty
Summary
The facility failed to implement incident and/or unusual occurrence reports for three residents. Resident #12 experienced a mechanical lift tipping over during a transfer, but no incident report or investigation was conducted because the resident was not injured, although two staff members were hurt. The mechanical lift had a history of malfunctioning, which was known to the staff, but no maintenance sheet was filled out to address the issue. Resident #1 sustained a skin tear on her arm, but the facility did not investigate the cause. The skin condition report and nursing notes lacked details on how the injury occurred. Staff involved in the transfer did not notice the injury until later, and the resident was unable to communicate what happened due to severe cognitive deficits. Resident #17 was found with scratches on her arms, but the facility did not complete an incident report or investigation. The resident had a history of combative behavior, and staff reported frequent injuries from the resident. The facility did not hold formal interdisciplinary team meetings to discuss root causes or potential solutions for the resident's behavior, relying instead on informal discussions and care pathways.
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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