Careage Hills Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Cherokee, Iowa.
- Location
- 725 North Second Street, Cherokee, Iowa 51012
- CMS Provider Number
- 165428
- Inspections on file
- 18
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Careage Hills Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident who was totally dependent on staff for transfers and had advanced dementia and seizure disorder was injured when a CNA attempted a mechanical lift transfer alone, contrary to facility policy requiring two staff. The resident fell from the lift, sustaining a forehead laceration, nasal fracture, and multiple skin tears. Documentation and interviews confirmed the CNA did not seek required assistance, resulting in the incident.
A resident with multiple sclerosis was left without an accessible call light after her adaptive pad call light broke and was not returned, leaving her unable to call for assistance. Staff confirmed that neither the standard call light nor alternative solutions were usable or consistently available for the resident, contrary to facility policy requiring a means of communication with nursing staff.
The facility failed to complete a wound treatment as ordered for a resident with pressure ulcers after a dressing was removed, resulting in a significant delay before the treatment was performed. Additionally, staff did not complete or document an assessment for another resident after seizure-like activity was reported, with the responsible RN not returning to reassess due to personal health issues.
The facility failed to follow professional food safety standards during meal preparation and serving. The Dietary Supervisor (DS) was observed using the same gloves to touch various surfaces and handle ready-to-eat food without washing hands between tasks. The facility's food handling policy and the 2022 Food Code require proper glove use and handwashing to minimize contamination risk.
A facility failed to obtain bed hold notifications for a resident hospitalized twice. The resident's EHR confirmed the hospitalizations, but no bed hold form was available for review. The Administrator admitted the oversight and explained that a Performance Improvement Program (PIP) was in place. The facility's policy requires written notification of bed hold provisions upon admission and before hospital transfer, with a copy in the resident's health record.
A resident with severe cognitive impairment and multiple health conditions experienced a significant weight loss of 14.3% over a month, with no subsequent weights recorded. The facility failed to adhere to its policy of monitoring and addressing weight loss, as the Registered Dietitian did not address the issue, and the prescribed nutritional supplements were not administered. The Director of Nursing acknowledged the policy requirements, but the facility did not follow through with necessary evaluations and interventions.
A resident with severe cognitive deficits was pushed by another resident, resulting in a fall and a hematoma. The incident occurred after lunch, and staff did not witness it directly. The injured resident was known to become agitated, especially when waiting for cigarette breaks. The facility's abuse prevention policy was not effectively implemented to prevent this incident.
The facility failed to investigate an alleged abuse incident involving a resident with severe cognitive deficits, as well as an injury of unknown origin for another resident. In both cases, there was a lack of documentation, witness statements, and incident reports, which is a deficiency in the facility's compliance with its policies.
The facility failed to provide adequate supervision and safety measures, resulting in accidents for several residents. A resident fell from a recliner due to improper transfer practices, while another was left unattended on the toilet, leading to a fall. A resident slid off a whirlpool seat due to inadequate securing, and another sustained a fracture when a staff member's dog caused her to fall. Ineffective interventions and lack of supervision led to multiple falls for another resident.
A resident with moderate cognitive deficits and a history of falls experienced multiple falls due to the facility's failure to implement care plan interventions. Despite requiring assistance with mobility, staff did not consistently follow interventions such as having a wheelchair behind the resident during ambulation and keeping the walker out of sight. Observations showed these measures were not adhered to, contributing to the resident's repeated falls.
A resident with severe cognitive impairment and multiple health issues fell in the bathroom during a transfer due to a CNA not using a gait belt, resulting in an acute fracture of the right femur neck. The facility's policy mandates gait belt use during transfers, which was not followed.
The facility failed to provide reasonable access to personal funds for two residents, limiting access to $10 after business hours and on weekends, and requiring advance requests for additional funds. This practice did not align with the facility's policy to protect and ensure accessibility of personal funds.
The facility failed to complete the required Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry, and Professional License information prior to the re-employment of two staff members, an LPN and a CNA. The oversight was confirmed by the Business Office Manager and the Executive Director, despite facility policies mandating pre-employment screening.
The facility failed to obtain bed hold notifications for a resident who was hospitalized. Clinical records showed the resident was in the hospital, but no bed hold form was available. Interviews with the Administrator and DON confirmed the expectation to obtain bed hold notifications for all transfers or discharges, as per facility policy.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, seizure disorder, and total dependence on staff for all activities of daily living, including transfers, was injured during a transfer using a mechanical lift. The resident's care plan specified the need for two staff members to assist with all mechanical lift transfers. Despite this, a Certified Nursing Assistant (CNA) attempted to transfer the resident alone using a Hoyer lift, contrary to facility policy and the resident's care plan. During the transfer, the CNA raised the resident in the sling and attempted to move her toward a wheelchair. The resident began to lean forward and subsequently fell out of the sling, landing face-first on the floor. The CNA immediately called for nursing assistance. Upon arrival, nursing staff found the resident on the floor with significant head trauma, including a forehead laceration, nasal fracture, and multiple skin tears. Emergency services were called, and the resident was transported to the hospital for further evaluation and treatment. Interviews and documentation confirmed that the CNA did not request assistance from another staff member prior to the transfer, despite knowing that two staff were required. The CNA stated that other staff were occupied and felt she had no other choice but to proceed alone. Facility policy explicitly required two staff for all mechanical lift transfers, and this policy was not followed in this instance, directly leading to the resident's fall and injuries.
Failure to Provide Accessible Call Light for Resident with Physical Limitations
Penalty
Summary
The facility failed to provide an adaptive call light for a resident with multiple sclerosis who was unable to operate a standard button call light. The resident had previously been given a pad call light that she could use, but it broke and was removed by the facility for repair, after which it was not returned. During an observation of a transfer using a mechanical lift, the resident confirmed she had no means to call for assistance in her room. Staff interviews corroborated that the resident was unable to use the standard pendant call light and that alternative solutions, such as a bell, were not consistently available or accessible. Facility policy requires that residents be provided with a means of communication with nursing staff, but this was not met for the resident in question.
Failure to Complete Wound Treatment and Seizure Assessment
Penalty
Summary
The facility failed to complete a wound treatment as ordered for one resident and failed to complete an assessment for another resident. For the first resident, who had diagnoses including type 1 diabetes and pressure ulcers, staff did not perform a prescribed wound treatment to the left ischium in a timely manner after the dressing was removed following a bowel movement. The resident reported the dressing was removed around 4:30 AM, but the wound treatment was not completed until 9:30 AM. Interviews revealed that the assigned RN did not complete the treatment due to not feeling well and was unable to stand long enough to perform the procedure. The DON was informed of the situation and instructed the RN to review the physician orders and complete the treatment, but the RN deferred the task to the next shift. For the second resident, who had Alzheimer's disease, a seizure disorder, and was dependent on staff for all activities of daily living, staff failed to complete and document an assessment after seizure-like activity was reported by CNAs. The RN on duty was notified of pre-seizure behavior but only performed a brief visual check, did not administer medication due to its expiration, and did not return to reassess the resident, citing personal health issues. Progress notes lacked documentation of an assessment related to the reported seizure activity, contrary to facility policy requiring assessment and documentation when seizure activity occurs.
Failure to Follow Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the preparation and serving of a meal. During an observation, the Dietary Supervisor (DS) was seen removing gloves, washing hands, and applying new gloves before starting to serve the noon meal. However, the DS then proceeded to touch various surfaces, including plates, utensils, steam table covers, diet cards, and menus, without changing gloves. The DS retrieved a bun from its bag with the same gloves and used tongs to place a hamburger on the bun. After sending the hamburger out, the DS changed gloves without washing hands and continued to serve food, touching multiple surfaces. The DS also made a peanut butter sandwich and handled a package of cheese, removing a slice with the same gloves that had touched other surfaces. The facility's Guidelines for Food Handling policy stated that food should be handled in a manner that minimizes contamination risk, and ready-to-eat foods should not be touched with bare hands. The policy required proper use of utensils and gloves, including washing hands before and after wearing or changing gloves. The 2022 Food Code also documented that single-use gloves should be used for only one task and discarded when soiled or when interruptions occur. The Dietician confirmed that gloves touching other surfaces should not be used to handle ready-to-eat food, and handwashing is necessary when changing gloves.
Failure to Obtain Bed Hold Notifications for Hospitalized Resident
Penalty
Summary
The facility failed to obtain bed hold notifications for a resident who was hospitalized on two separate occasions. The resident's Electronic Healthcare Record (EHR) confirmed hospitalizations, but there was no bed hold form available for review for these dates. During an interview, the Administrator acknowledged that the bed holds were missed and explained that a Performance Improvement Program (PIP) had been initiated after the last annual survey. The Administrator was responsible for auditing the bed holds at the time, and the process required a bed hold form to be completed for any resident going out, with verbal consent obtained if the resident was unable to sign. The facility's policy, revised in 2016, mandates informing the resident or their representative in writing about the bed hold provision upon admission and before hospital transfer, with a copy of the notification included in the resident's health record.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adhere to its policy regarding significant weight loss for a resident with severe cognitive impairment, diabetes mellitus, cerebrovascular accident, and non-Alzheimer's dementia. The resident experienced a significant weight loss of 14.3% over a period from December 2024 to January 2025, with no subsequent weights recorded after January 8, 2025. Despite the facility's policy requiring monthly weights and additional monitoring for residents with weight loss, the resident's weight was not monitored weekly as required. Furthermore, the Registered Dietitian's progress note on February 5, 2025, did not address the resident's weight loss, and the facility failed to implement the physician's order to increase nutritional supplements. The Director of Nursing acknowledged that the facility's policy is to conduct monthly weights and weekly weight meetings, with additional measures for residents experiencing weight loss. However, the facility did not follow through with these procedures for the resident in question. The facility's policy also mandates that any significant weight change should be evaluated by the Interdisciplinary Team, but there is no evidence that this evaluation occurred. The lack of adherence to the facility's nutrition policy and failure to implement prescribed interventions contributed to the deficiency in maintaining the resident's nutritional status.
Resident Abuse Incident Leading to Injury
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an incident where one resident pushed another, causing the latter to fall and sustain a hematoma on the back of his head. The resident who was pushed had a severe cognitive deficit, as indicated by a BIMS score of 5, and was known to have periods of agitation. The incident occurred after the resident had finished lunch and was pacing the hallway, eventually sitting near a fish tank. The altercation happened when another resident, also with a severe cognitive deficit, pushed him, leading to the fall. The incident was reported by the nurse on duty who heard a loud bang and found the resident on the floor. The resident accused another resident of pushing him, which was corroborated by other residents who witnessed the event. The injured resident was taken to the emergency room, where a small subdural hematoma was diagnosed. Despite the injury, the resident was returned to the facility with instructions for increased monitoring. Interviews with staff revealed that none of them witnessed the incident directly, but they were aware of the resident's tendency to become agitated, especially when waiting for cigarette breaks. The staff also noted that the resident had previously shown aggressive behavior towards others. The facility's Director of Nursing and Administrator were unaware of any prior aggressive behavior from the resident who pushed, and the facility's policy on abuse prevention and reporting was not effectively implemented to prevent this incident.
Failure to Investigate Alleged Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident involving a resident with severe cognitive deficits. The incident occurred when a resident was found on the floor, claiming to have been pushed by another resident. Despite the seriousness of the allegation, the Director of Nursing (DON) did not have documentation of witness statements, and staff members who were present did not recall being interviewed or providing signed statements. This lack of thorough investigation and documentation is a deficiency in the facility's response to alleged abuse. Additionally, the facility did not investigate an injury of unknown origin for another resident, who also had severe cognitive deficits. This resident was found with scattered bruising on her lower extremities, but there was no documentation of an investigation into the cause of the bruising. Nursing notes indicated the presence of bruising, but lacked detailed descriptions or measurements. Staff members acknowledged the bruising but did not follow the facility's policy to initiate a risk management incident report or conduct a thorough investigation. The facility's policy requires that all alleged violations, including injuries of unknown origin, be thoroughly investigated. However, in both cases, the facility failed to adhere to its policy, as evidenced by the lack of documentation, witness statements, and incident reports. This failure to investigate and document alleged abuse and injuries of unknown origin constitutes a deficiency in the facility's compliance with its own policies and procedures.
Inadequate Supervision and Safety Measures Lead to Resident Accidents
Penalty
Summary
The facility failed to ensure proper supervision and use of interventions to prevent accidents for five residents. Resident #1, who was totally dependent on staff for transfers, fell from a recliner and sustained injuries due to improper transfer practices by staff. The CNA involved did not use a gait belt and moved the resident before a nurse could assess her, leading to further complications. Additionally, Resident #5, who required substantial assistance, was left unattended on the toilet without a gait belt or proper footwear, resulting in a fall. Resident #3, with moderate cognitive deficits and impaired mobility, slid off a whirlpool seat during a bath due to inadequate securing with safety straps. The staff member responsible lacked specific training on the use of the whirlpool bath, which contributed to the incident. Furthermore, Resident #4, who had intact cognitive ability, sustained a fracture when a staff member's dog, not on a leash, slid into her, causing her to fall. The facility's policy on pet management was not adhered to, leading to this accident. Resident #2, with moderate cognitive deficits and a history of falls, experienced multiple falls due to ineffective interventions and lack of supervision. The care plan interventions, such as keeping the walker out of sight and having a wheelchair behind the resident when ambulating, were not consistently implemented. The facility's policies on gait belt use and fall management were not followed, contributing to the residents' accidents and injuries.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions established in the care plan to prevent falls for a resident with a history of falls. The resident, who had moderate cognitive deficits and required assistance with mobility, experienced multiple falls despite specific interventions outlined in her care plan. These interventions included having a wheelchair behind her when ambulating and placing her walker out of sight to prevent her from reaching for it. However, observations revealed that these interventions were not consistently followed by the staff, as evidenced by the resident being found with her walker within reach and without a wheelchair behind her during ambulation. The resident's care plan was not effectively communicated or implemented, leading to repeated falls. Staff members, including a CNA and the DON, acknowledged the challenges in finding effective interventions due to the resident's belief in her ability to self-transfer. The DON also expressed uncertainty about the continued implementation of certain interventions, indicating a lack of clarity and consistency in the care plan's execution. This failure to adhere to the care plan contributed to the resident's repeated falls, highlighting a deficiency in the facility's care practices.
Failure to Use Proper Transfer Techniques Resulting in Resident Injury
Penalty
Summary
The facility failed to provide proper transfer techniques while transferring a resident, leading to an accident. Resident #21, who has severe cognitive impairment, aphasia, stroke, hemiplegia, difficulty in walking, and requires assistance with personal care, fell in the bathroom during a transfer. Staff A, an LPN, found Resident #21 on the floor without a gait belt and showing non-verbal cues of pain. The resident was transferred to a wheelchair using a gait belt and sent to the emergency room, where an acute fracture of the right femur neck was diagnosed, requiring surgical repair. Staff B, a CNA on her first or second day, admitted to not using the gait belt during the transfer, which led to the fall. Staff B revealed that she had removed the gait belt after positioning Resident #21 on the toilet and stepped outside the bathroom door to give privacy, during which the resident fell. The facility's policy mandates the use of gait belts during transfers and ambulation for non-independent residents. Staff B had received training on gait belt use and transfer techniques but failed to adhere to the policy. The Director of Nursing confirmed that gait belts should be used at all times during transfers and kept on residents when toileting. The facility conducted an in-service training on gait belt use and transfer techniques following the incident.
Failure to Provide Reasonable Access to Personal Funds
Penalty
Summary
The facility failed to provide ready and reasonable access to personal funds upon request for two residents. Resident #30 reported that they could not access money when needed because the responsible person was not available, and they had to plan ahead for the weekend. Resident #25 mentioned that they had not asked for money because the staff responsible for funds was not available on weekends, and they would have to call their son if they needed money. Interviews with staff confirmed that residents could only access up to $10 from their funds after business hours and on weekends, and any additional amount had to be requested in advance. The funds available in the envelopes of Resident #25 and Resident #30 were found to be insufficient, with only 29 cents and $7.75 respectively. The facility's policy stated that personal funds should be protected and accessible, but the practice of limiting access to $10 and requiring advance requests for more funds did not align with this policy. The Operations Manager acknowledged ongoing discussions to improve access to personal funds, but no effective solution had been implemented at the time of the survey. The deficiency was identified based on the facility's failure to ensure residents had reasonable access to their personal funds as needed, particularly after business hours and on weekends.
Failure to Complete Pre-Employment Background Checks
Penalty
Summary
The facility failed to complete the required Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry, and Professional License information prior to the re-employment of two staff members, Staff E (LPN) and Staff F (CNA). Staff E was rehired on 7/18/22, and Staff F was rehired on 10/11/22. On 3/26/24, it was discovered that their personnel files did not contain the necessary background checks. The Business Office Manager confirmed that the background checks were not completed before these staff members began working. The Executive Director also confirmed this oversight. The facility's policies, revised in January 2022 and May 2007, clearly state that pre-employment screening must be completed before employment begins to ensure that potential employees do not have disqualifying events and have the appropriate certification.
Failure to Obtain Bed Hold Notification
Penalty
Summary
The facility failed to obtain bed hold notifications for a resident who was transferred to the hospital. Clinical record review revealed that the resident was hospitalized from 11/1/23 through 11/4/23, but there was no bed hold form available for these dates. During interviews, both the Administrator and the Director of Nursing confirmed that their expectation was to obtain a bed hold notification every time a resident is transferred or discharged. The facility's policy, revised in 11/2016, mandates that residents or their representatives be informed in writing of their right to exercise the bed hold provision in the event of a transfer to a general acute care hospital. However, this procedure was not followed for the resident in question.
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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