Caring Acres Nursing And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Anita, Iowa.
- Location
- 1000 Hillcrest Drive, Anita, Iowa 50020
- CMS Provider Number
- 165217
- Inspections on file
- 27
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at Caring Acres Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility was repeatedly cited for deficiencies related to its QAPI program, including failures to report and investigate incidents, as documented in multiple complaint investigations. Despite having a QAPI/QAA plan in place, the same types of deficiencies recurred over an extended period, indicating that the facility's processes for identifying and correcting quality issues were not effective.
A resident with significant physical impairments and no cognitive deficits was allegedly handled roughly by a CNA during repositioning, leading to a delay in reporting the incident by another CNA who witnessed the event. The concern was not reported to management or the state agency within the required two-hour timeframe, as mandated by facility policy.
A resident with no cognitive impairment reported missing money from her room. The facility's investigation was incomplete, lacking staff and resident interviews, and the investigative file could not be located. Required documentation and witness statements were not obtained as outlined in facility policy.
Two residents experienced significant changes in condition—one with acute illness and another following a fall with pain—yet staff failed to provide timely assessment, notify providers, administer PRN medications, or follow facility protocols for transfer and pain management. These deficiencies resulted in delayed interventions and inadequate care, as confirmed by staff interviews and record reviews.
Three residents experienced a lack of dignity and respect, including a resident with dementia repeatedly denied bathroom assistance and spoken to harshly, a cognitively intact resident subjected to discriminatory language and neglect by a CNA, and another resident left exposed in a common area until staff intervened. Facility leadership acknowledged these actions did not meet expectations for resident care.
A resident with cognitive impairment and behavioral health needs was subjected to verbal abuse by an LPN following a fall, with the LPN making belittling and derogatory remarks about the resident's actions and appearance. Staff interviews confirmed a pattern of inappropriate and abrasive communication by the LPN toward multiple residents, in violation of the facility's abuse prevention policy.
A resident with cognitive impairment and behavioral health diagnoses was subjected to belittling and derogatory comments by an LPN after a fall, with the incident not being reported to management within the required timeframe. Staff interviews revealed uncertainty about the abuse reporting process, and additional concerns were raised about another CNA's conduct, with staff failing to consistently report resident complaints as required by policy.
A resident with multiple chronic conditions did not have proper documentation for the administration of a PRN medication for constipation, and staff failed to follow up on its effectiveness. Nursing staff were unable to confirm when the medication was given or if it was effective, and the required documentation was missing from the MAR, contrary to facility policy.
A resident with mild cognitive impairment and multiple comorbidities was found on the floor after a fall and complained of hip pain. Despite her inability to move her leg without pain, a CNA and an LPN manually lifted her back to bed instead of using a mechanical lift as required by facility policy. The DON confirmed that the proper transfer procedure was not followed.
The facility inaccurately submitted the 4th quarter 2024 PBJ report, showing low weekend staffing and insufficient RN coverage due to missing agency staff hours. The new Administrator, in place since January, noted the absence of a policy for PBJ submissions, contributing to the deficiency.
The facility's QAPI policy lacked essential descriptions for identifying and analyzing adverse events, obtaining resident feedback, and monitoring performance improvements. The Interim Administrator acknowledged these deficiencies, noting incomplete QAPI activities.
The facility did not maintain records of QAA meetings for three out of four quarters, only documenting meetings in April and June of the same quarter. Despite a policy requiring quarterly meetings, the Interim Administrator confirmed the lack of documentation for the remaining quarters. The facility's QAPI policy indicated that meetings should occur monthly or quarterly.
The facility failed to maintain proper infection control and hygiene practices. Staff did not adhere to hand hygiene protocols after assisting residents with toileting, and laundry was not delivered covered. These deficiencies were acknowledged by the facility's administration.
The facility failed to follow physicians' orders for four residents, resulting in missed wound treatments and medication errors. A resident with pressure ulcers did not receive prescribed treatments due to supply shortages, and another resident received an incorrect dosage of simethicone. Additionally, a resident was left unsupervised with medication, and another was nearly given the wrong medication. The facility lacked a policy for medication administration, contributing to these deficiencies.
The facility failed to ensure the safety of residents by not conducting daily checks on Wander Guard alarms for two residents at risk of elopement and not following proper transfer techniques for two other residents. Staff were not adequately trained in using safety devices, and the facility lacked a policy on Wander Guard checks. These deficiencies put residents at risk of harm.
The facility failed to ensure competent care by relying on inadequately oriented Agency Staff (AS). A significant portion of the nursing staff were AS, and one LPN admitted to not knowing how to check wander guards due to lack of orientation. The facility had recently created an orientation checklist, but there was no evidence of its completion by AS. Residents were upset by late medication administration when only AS were on duty, and AS often sought help from non-nursing staff to find supplies.
The facility failed to employ a staff member with specialized training in infection prevention and control, as required by their job description manual. The ADON claimed to be certified but could not provide documentation, and the Interim Administrator confirmed the absence of certification records. Despite requests, the facility could not produce any certifications for infection prevention and control.
The facility failed to ensure documentation and administration of pneumococcal immunizations for four residents, as their EHRs lacked records of consent, declination, or receipt of the vaccine. Despite the facility's expectation to offer immunizations per federal regulations, interviews revealed that these residents were neither offered nor documented to have received the immunizations.
The facility failed to document COVID-19 vaccination offers and statuses for four residents, including those with moderate cognitive impairment. Despite the facility's policy and federal regulations, there was no record of consent or declination for the COVID-19 vaccine in their EHRs. The oversight was acknowledged by the Regional Nurse Consultant and Interim Administrator.
The facility failed to ensure that all CNAs completed the required 12 hours of continuing education annually. A review of personnel files revealed that two CNAs did not have documentation of the necessary training hours. The Administrator acknowledged the lack of a policy on CNA annual training requirements, despite having an in-service schedule and an Annual In-Service Calendar indicating a plan for monthly education.
The facility failed to provide a homelike environment by not ensuring warm water in resident rooms. Multiple residents reported the issue, and observations confirmed the water remained cool. The maintenance supervisor had not conducted recent temperature checks, and a plumber found that the recirculators were not working properly.
The facility failed to conduct a background check before hiring a DON who was listed on the Child Abuse Registry. Despite the facility's policy against employing individuals with abuse findings, there was no follow-up inquiry into the registry listing. Staff interviews revealed a lack of communication and responsibility in the hiring process, with the current Administrator mistakenly believing the background check was clean.
The facility failed to complete the PASARR process for two residents, leading to deficiencies in their care plans. One resident's antipsychotic medication was not documented in the MDS, and a new PASARR was not completed after updated psychiatric diagnoses. Another resident's care plan did not incorporate PASARR Level II recommendations for Schizophrenia, and the facility lacked a PASARR policy.
A facility failed to identify target behaviors for psychotropic medication use for a resident with bipolar disorder. The resident was prescribed Caplyta and Trazadone for depression, but the Caplyta was intended for bipolar disorder. The physician orders lacked target behaviors, and the facility did not have a policy for identifying them. The ADON and Interim Administrator acknowledged the discrepancies in medication orders and diagnoses.
The facility failed to submit information about four residents who are veterans to the Iowa Department of Veterans Affairs. The facility did not ensure these residents completed the Veteran's Questionnaire, which is necessary for determining eligibility for veteran benefits. The Interim Administrator acknowledged the oversight, and the facility lacked a policy for inquiring about veterans' benefits.
The facility failed to provide dignified care to three residents by not offering timely assistance with toileting and maintaining privacy. A resident waited over 45 minutes for toileting assistance, another soiled herself due to delayed response to call lights, and a third was publicly told she needed to change her wet pants. The facility's policy on abuse prevention was violated, as acknowledged by the Administrator.
The facility failed to provide adequate nurse staffing, resulting in delayed care for residents. A resident reported long waits for call light responses, impacting their rehabilitation and daily care. Another resident, at risk for skin breakdown, experienced delays in incontinence care. An LPN worked excessively long hours due to staffing shortages. The facility's staffing plan was deemed unrealistic, and there was no policy on call light response times.
The facility did not ensure RN coverage for 8 consecutive hours daily, with four days lacking RN presence. The DON acknowledged the issue, and the Nurse Scheduler cited challenges in staffing due to reliance on agency nurses. No policy on RN coverage was in place, despite the facility assessment's requirements.
A resident admitted for rehabilitation did not have a documented care plan, despite a care conference discussing his needs. The resident, who was cognitively intact, was dissatisfied with the lack of planning, inadequate equipment, and delayed physical therapy, which affected his rehabilitation progress. The DON acknowledged the absence of a care plan and noted the facility's lack of a specific care planning policy.
A resident admitted with a knee injury and requiring therapy services was accepted by the facility without considering his bariatric equipment needs. The staff was unaware of the necessary equipment, resulting in the resident being mostly bed-ridden for over two weeks until the equipment arrived. This delay hindered his rehabilitation progress and required his family to purchase a suitable walker.
A resident in a LTC facility reported feeling unsafe and fearful due to alleged rough care and inappropriate language by a CNA. The resident, with a BIMS score of 15 and a history of cerebral palsy, anxiety, and PTSD, expressed discomfort and soreness after care. Despite reports of verbal abuse, the CNA continued working, though not with the resident. The facility's inadequate response to the resident's concerns led to a deficiency finding.
A resident with cerebral palsy and other medical conditions reported verbal abuse by a staff member, which was not promptly reported to the State Agency by the facility. The incident involved inappropriate language and behavior by the staff, leading to the resident feeling unsafe. The Assistant Director of Nursing, related to the accused staff, failed to escalate the matter, resulting in a delay in reporting and an Immediate Jeopardy situation identified by the State Agency.
A resident in an LTC facility experienced psychosocial harm due to an altercation with a CNA, Staff A, who allegedly made inappropriate comments. Despite the resident's grievances and visible distress, Staff A returned to work after completing abuse education, although not allowed to care for the resident directly. The resident continued to feel unsafe and expressed concerns about potential retaliation, highlighting a deficiency in the facility's handling of the incident.
The facility failed to follow physician orders and administer medications correctly for two residents. A resident with severe cognitive impairment did not receive Lidocaine cream as ordered before a wound dressing change, and there was no documented order for physician notification regarding weight gain. Another resident did not receive potassium chloride due to a transcription error upon admission, which was only discovered during a monthly medication review. The DON acknowledged these errors, highlighting lapses in medication administration and order transcription processes.
The facility experienced significant service disruptions due to non-payment to local vendors, including waste removal and transportation services. Staff reported overflowing garbage and missed medical appointments for residents. The administration was aware of the outstanding balances and communicated with the corporate office, but delays in payment persisted, affecting the facility's operations.
The facility failed to notify the Long-Term Care Ombudsman of hospital transfers for two residents. The required notifications were not made, and interviews with staff revealed that the responsibility for these notifications had recently changed hands. The facility's policy mandates that transfer and discharge notices must be sent to the Ombudsman, but this was not adhered to.
The facility failed to obtain bed hold notifications for two residents during their hospital transfers. The EHR confirmed the hospitalizations, but no bed hold forms were found. Interviews with staff revealed that the expectation was to obtain bed hold notifications every time a resident is transferred out of the facility, as stated in the facility's Bed Hold Policy.
The facility failed to review and revise the care plan for a resident receiving anticoagulant therapy for a history of an acute embolism and thrombosis. Despite routine administration of the medication, the care plan did not include directives for the therapy. The DON confirmed that the care plan should be updated within one week after a status change, as per policy.
Repeated QAPI Program Deficiencies and Failure to Report/Investigate
Penalty
Summary
The facility failed to ensure the implementation of a comprehensive and effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by repeated deficiencies identified during multiple complaint investigations. Specifically, the facility was cited for failures to report and investigate incidents, with deficiencies noted on several occasions, including failures to report (Tag 609) and failure to investigate (Tag 610). These repeated deficiencies were documented over a period spanning from August 2023 to June 2025, indicating ongoing issues with the facility's processes for identifying and correcting quality problems. A review of the facility's QAPI/QAA plan revealed that, while a policy document existed with a stated purpose of continuous quality improvement and staff participation, the actual practices did not prevent the recurrence of the same deficiencies. Staff interviews and policy reviews confirmed that the facility's approach was not effective in addressing or preventing the cited issues, as the same types of deficiencies continued to be identified during subsequent complaint investigations.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident who had no cognitive impairment and was dependent on staff for mobility and hygiene due to multiple medical conditions, including cerebral palsy and neurogenic bladder. On the evening of the incident, a CNA witnessed another CNA repositioning the resident in a manner perceived as rough and too quick, which caused the resident to verbally express discomfort and ask the staff member to stop. The witnessing CNA did not immediately report the incident, instead waiting until the following day to notify the provisional administrator, believing she had up to two days to report the concern. Facility policy required that all allegations of abuse, neglect, or mistreatment be reported to the state agency within two hours of the allegation being made. Interviews with staff and review of the investigative file confirmed that the concern was not reported within the required timeframe. The Director of Nursing and the administrator both acknowledged that the reporting should have occurred as soon as possible or within two hours, in accordance with policy and regulatory requirements.
Failure to Complete Thorough Investigation of Missing Resident Property
Penalty
Summary
The facility failed to conduct a thorough investigation after a resident reported that $90 was missing from her room. The resident, who had no cognitive impairment and multiple medical diagnoses including cerebral palsy, anxiety, and PTSD, kept her money in a specific location in her dresser. Upon discovering the money was missing, she notified staff and the facility replaced the funds. However, the facility's 5-day investigation only included the resident's statement, a timeline of the incident, and a plan of action, but did not include interviews with staff or other residents. Further review revealed that the Director of Nursing was not present at the time of the incident and deferred to another staff member who completed the investigation, but the investigative file could not be located by the Administrator. The only documentation submitted to the State Agency included the resident's care plan, facesheet, and a 5-day summary. The facility's policy requires obtaining witness statements and thorough documentation, but these steps were not completed or could not be verified due to missing records.
Failure to Assess and Intervene After Change in Condition and Fall
Penalty
Summary
The facility failed to provide proper assessments and interventions following changes in condition for two residents. One resident, with a history of Parkinson's Disease, coronary artery disease, and diabetes mellitus, experienced a significant change in condition, including fever, altered mental status, and abnormal vital signs. Despite staff reporting concerns about the resident's condition, including changes in bowel movements, decreased appetite, confusion, and fever, the nurse on duty did not assess the resident or notify the physician in a timely manner. The only intervention provided was a cold rag for the fever, and no PRN medication was administered. The physician was not notified until the resident's condition deteriorated significantly, at which point the resident was sent to the hospital and subsequently expired from sepsis due to aspiration pneumonia. Another resident, with dementia and multiple psychiatric and medical diagnoses, suffered an unwitnessed fall and complained of left hip pain. Staff failed to call the provider for a PRN pain order or for evaluation after the fall. The resident was not sent to the hospital until approximately 12 hours later, where a left hip fracture was diagnosed. Documentation and staff statements revealed that the resident was moved from the floor to the bed without the use of a mechanical lift, contrary to facility protocol, and that pain complaints were not adequately addressed or managed. The resident did not have a PRN pain medication order until after returning from the hospital. Facility policy required prompt assessment, notification of changes in condition, and appropriate interventions, including contacting the medical provider and documenting all significant changes. In both cases, staff failed to follow these protocols, resulting in delayed assessment, lack of timely intervention, and inadequate communication with medical providers and the DON. These failures were corroborated by staff interviews, clinical record reviews, and facility documentation.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to honor residents' rights to dignity and respect, as evidenced by multiple incidents involving three residents. One resident with severe cognitive impairment and a history of dementia, anxiety, depression, bipolar disorder, and PTSD was repeatedly denied timely assistance to use the bathroom. Staff instructed the resident to sit down and dismissed her requests, leading to increased anxiety and agitation. Observations showed staff raising their voice and refusing to assist, despite the resident's clear indications of need and distress. Another resident, who was cognitively intact and dependent on staff for all mobility and self-care, reported that a staff member used discriminatory language and was rude, refusing to assist both the resident and other staff members. The resident stated that these actions made her feel bad and that she had reported the concerns to previous facility leadership. A third resident with severe cognitive impairment and dementia was observed sitting in a common area with her shirt pulled up, exposing her breast, while other residents and staff passed by without addressing the situation. The exposure was only corrected after several minutes when a staff member entered the room and assisted the resident. Facility leadership acknowledged that staff are expected to be aware of their surroundings and ensure residents' needs are met, but this expectation was not met in these instances.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with mild cognitive impairment and multiple behavioral and mental health diagnoses was subjected to verbal abuse by a staff member. The resident, who required supervision for mobility and had a history of confusion and dementia, was found on the floor by a CNA after attempting to get a drink of water. During the incident, the LPN on duty made belittling and derogatory comments to the resident, including remarks about the resident's fall, her use of the call light, and her body size. The LPN also made statements that were described as cold, abrasive, and nonchalant, which were witnessed and reported by other staff members present during the incident. Staff interviews and statements corroborated that the LPN's interactions with residents were often rude, unapproachable, and inappropriate, particularly with residents who exhibited behavioral issues or dementia. The LPN was reported to have made dismissive and agitating comments to another resident regarding her pets and family, further demonstrating a pattern of verbal mistreatment. The facility's internal investigation substantiated the verbal abuse allegations, and the LPN's employment was subsequently terminated. The facility's policy clearly prohibits all forms of abuse, including verbal abuse, and defines it as the use of disparaging or derogatory language toward residents. Despite this policy, the LPN's conduct toward the resident after her fall, as well as toward other residents, constituted verbal abuse as defined by the facility. The resident involved was unable to participate in an interview due to cognitive limitations, but multiple staff accounts provided consistent evidence of the inappropriate and abusive language used by the LPN.
Failure to Timely Report Alleged Verbal Abuse and Mistreatment
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse by a staff member toward a resident to the appropriate management staff, as required by facility policy and regulatory requirements. The incident involved a resident with mild cognitive impairment and multiple behavioral and mental health diagnoses, who was found on the floor by a CNA. The LPN on duty responded and made belittling and derogatory comments to the resident during the assessment and transfer back to bed. The CNA present reported that the LPN's tone was inappropriate and that the comments included disparaging remarks about the resident's fall, physical appearance, and decision-making. The CNA did not immediately report the incident, stating he was unsure of the reporting process at the time and waited until the next day to notify management. The facility's policy required that any employee or agent who becomes aware of abuse or neglect immediately report the matter to the Administrator or their designee, and that all alleged violations involving abuse, neglect, exploitation, or mistreatment be reported to the Administrator and the mandated state agency within two hours. However, the report of the incident was delayed, and the required notification to management and authorities was not made within the specified timeframe. Staff interviews confirmed that there was a lack of clarity among some staff regarding the reporting protocol, and that education on the abuse protocol and reporting timeframes was subsequently provided. Additionally, there were reports from another resident regarding a different staff member, an agency CNA, who was alleged to have used discriminatory language and refused to assist with care. Multiple staff members acknowledged hearing complaints from the resident about this CNA, but did not recall reporting these concerns to administration, often attributing the complaints to the resident's general dissatisfaction. The DON and Administrator both stated that all suspected abuse should be reported for investigation, regardless of the resident's history of complaints.
Failure to Document PRN Medication Administration and Effectiveness
Penalty
Summary
Staff failed to properly document the administration of a PRN medication and did not follow up to assess its effectiveness for a resident with Parkinson's Disease, coronary artery disease, and diabetes mellitus. The resident, who was frequently incontinent and required moderate assistance with activities of daily living, had an active order for milk of magnesia as needed for constipation. Review of the Medication Administration Record (MAR) showed that the medication was not signed out as given during the period it was ordered. Staff interviews revealed uncertainty about when the medication was administered and whether its effectiveness was evaluated, with the nurse responsible unable to recall the specific day or if documentation was completed. Further interviews with CNAs indicated that the resident did not have a bowel movement as expected and exhibited changes in condition, which were reported to the nurse. The facility's bowel policy required nurses to assess residents who had not had a bowel movement, document findings, and follow up on PRN medication effectiveness, but these steps were not followed. The Director of Nursing confirmed that nurses are expected to document administration and effectiveness of PRN medications, but this was not done in this case.
Failure to Use Mechanical Lift During Post-Fall Transfer
Penalty
Summary
Staff failed to properly transfer a resident following a fall in her room. The resident, who had mild cognitive impairment and multiple diagnoses including dementia and PTSD, was found on the floor by a CNA after attempting to reach for water and falling out of bed. The resident complained of significant hip pain and was unable to straighten her leg without pain. Despite these complaints, the CNA and an LPN lifted the resident from the floor back to her bed by placing their arms under her arms, rather than using a mechanical lift as required by facility policy and as later confirmed by the Director of Nursing. Staff statements and interviews confirmed that the resident expressed pain during the transfer and was unable to move her leg, yet the mechanical lift was not used. The facility's policy instructed staff to assess the resident and safely transfer them using appropriate equipment after a fall, but this was not followed. The incident was documented in progress notes and staff statements, and the Director of Nursing acknowledged that the correct procedure was not used in this situation.
Inaccurate PBJ Report Submission Due to Missing Agency Staff Hours
Penalty
Summary
The facility failed to accurately submit the required Payroll Based Journal (PBJ) quarterly report, which is essential for maintaining compliance with staffing regulations. The report for the 4th quarter of 2024 indicated issues such as low weekend staffing, insufficient Registered Nurse (RN) coverage for 8 consecutive hours per day, and concerns regarding 24-hour Licensed Nurses coverage. Additionally, the facility had a 1-star staffing rating. Upon investigation, it was revealed that the previous administration did not include agency staff hours in the PBJ report, leading to the inaccurate submission. The current Administrator, who assumed the role in January, acknowledged the oversight and mentioned the absence of a policy for submitting quarterly PBJ reports, which contributed to the deficiency.
Deficient QAPI Policy Implementation
Penalty
Summary
The facility failed to properly establish and implement written policies and procedures for its Quality Assurance and Performance Improvement (QAPI) plan. The facility's QAPI policy, updated in January, lacked essential descriptions on how to identify, report, track, investigate, and analyze adverse events or problem-prone concerns. Additionally, the policy did not include how feedback from resident representatives would be obtained and used to identify high-risk or problem-prone issues. Furthermore, the policy was missing a description of how the facility monitored the effectiveness of its performance improvement activities to ensure sustained improvements. The Interim Administrator acknowledged these deficiencies, noting that QAPI activities had only been completed for two months in the previous year.
Failure to Maintain QAA Meeting Records
Penalty
Summary
The facility failed to maintain records of Quality Assessment and Assurance (QAA) meetings for three out of four quarters reviewed. The facility, which reported a census of 25 residents, only provided documentation for QAA meetings held in April and June of the same quarter. No further documentation was available for the subsequent three quarters. The Interim Administrator acknowledged that the QAA committee had only met during the months of April and June, despite the facility's policy and expectation that the committee would meet at least quarterly. The facility's Quality Assessment and Performance Improvement (QAPI) policy, updated in January, indicated that the QAPI program should consist of monthly or quarterly meetings.
Inadequate Infection Control and Hygiene Practices
Penalty
Summary
The facility failed to implement adequate infection control measures, as evidenced by multiple instances of staff not adhering to proper hand hygiene protocols. Staff members were observed assisting residents with toileting without changing gloves or washing hands afterward. For instance, two CNAs assisted a resident with severe cognitive impairment in the bathroom, failed to change gloves after checking her brief, and did not wash their hands before leaving the bathroom. Similarly, another resident, who was cognitively intact but dependent on staff for hygiene, was assisted with toileting by staff who did not wash their hands after removing gloves and handling trash. Additionally, the facility's laundry procedures were found to be inadequate. The Laundry Supervisor admitted that laundry was not being delivered covered, as the delivery cart was repurposed for other uses. The Interim Administrator acknowledged the expectation for laundry to be covered during delivery, but there was no policy or procedure in place to ensure this practice. These lapses in infection control and hygiene practices were acknowledged by the facility's administration.
Deficiencies in Treatment and Medication Administration
Penalty
Summary
The facility failed to ensure that staff followed physicians' orders for four residents, leading to deficiencies in care. Resident #18, who was cognitively intact and had a history of paraplegia and pressure ulcers, did not receive the prescribed wound treatments on multiple occasions. The Treatment Administration Record (TAR) showed that treatments were missed without explanation on several days in December and January. Staff P, an LPN, reported that the facility often lacked the necessary supplies to complete the treatments, and there was no documentation of refusals or physician notifications as required by the facility's policy. Resident #14, who had severe cognitive impairment, was given an incorrect dosage of simethicone due to the unavailability of a half tablet. Staff J, an LPN, administered only one tablet instead of the prescribed 1.5 tablets, and the ADON acknowledged the error, stating that the medication should not have been split and that the physician should have been notified for a new order. This incident highlights a failure in medication administration and communication with the pharmacy and physician. Resident #20, who had no cognitive impairment, was left unsupervised with her medication, which she mistook for another drug. The Interim DON confirmed that the nurse should have observed the resident taking the medication. Additionally, Staff J attempted to give Resident #26 the wrong medication, which the resident refused, recognizing the error. The facility lacked a policy for medication administration, and the Interim Administrator and Regional Nurse Consultant acknowledged the need for adherence to the Rights of Medication Administration.
Failure to Ensure Safety and Proper Use of Devices
Penalty
Summary
The facility failed to implement necessary interventions to prevent accidents and hazards for four residents. Two residents identified as elopement risks were equipped with Wander Guard alarm bracelets, but staff did not ensure the alarms were functioning by conducting daily checks. The Maintenance Director only checked the Wander Guard functioning once a week, and the Assistant Director of Nursing assumed nurses were checking the devices, although they were not. Staff J, an LPN, admitted to never checking the Wander Guards and not knowing how to operate the device. The facility lacked a policy on Wander Guard checks, and the device used to check the Wander Guards was not readily available. Additionally, the facility failed to provide safe transfer techniques for two residents. One resident, with severe cognitive impairment and dependent on staff for mobility, was lifted unsafely by two CNAs who did not use a gait belt as expected. Another resident, who was cognitively intact but at high risk for falls, was transferred using an EZ Stand lift without properly securing the safety strap. The staff did not tighten the sling belt as required by the manufacturer's instructions, and the Administrator was unsure of the proper procedure. These deficiencies highlight a lack of adherence to safety protocols and inadequate staff training in the use of safety devices and transfer techniques. The facility's failure to ensure the proper functioning of elopement prevention devices and to follow safe lifting procedures put residents at risk of harm.
Inadequate Orientation and Training of Agency Staff
Penalty
Summary
The facility failed to ensure that competent and trained staff were providing resident care, as evidenced by the reliance on contracted Agency Staff (AS) who were not adequately oriented or trained. The nursing schedule revealed that 5 out of 7 nurses were AS, and one LPN admitted to not knowing how to check wander guards and not completing an orientation checklist. The facility had recently established an orientation checklist and a binder with resources, but there was no evidence of AS completing this checklist. Additionally, it was observed that residents were upset due to late medication administration when only AS were working, and AS frequently asked non-nursing staff for assistance in locating supplies.
Lack of Certified Infection Preventionist
Penalty
Summary
The facility failed to employ a staff member with specialized training in infection prevention and control, as required by their job description manual for the Infection Prevention (IP) Nurse position. The manual specifies that the IP Nurse must have current, specialized training and certification in Infection Control from an approved course. During the survey, the Assistant Director of Nursing (ADON) claimed to be certified in infection prevention but could not provide documentation to verify this. The Interim Administrator also confirmed that the facility did not have a copy of the IP nurse's certification and acknowledged the expectation that the IP nurse should have the appropriate certification. Despite requests for documentation, the facility was unable to produce any certifications or qualifications for any employee in infection prevention and control.
Failure to Document and Administer Pneumococcal Immunizations
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure that residents' medical records included documentation of pneumococcal immunizations. This deficiency was identified for four out of five residents reviewed, specifically Residents #6, #13, #17, and #20. The review of the Electronic Health Records (EHR) for these residents revealed a lack of documentation regarding consent or declination for the pneumococcal immunization, as well as no evidence that the residents had ever received the immunization. The Minimum Data Set (MDS) assessments indicated that Residents #6, #13, and #20 had no cognitive impairment, while Resident #17 had moderate cognitive impairment. During interviews, Staff M, a Regional Nurse Consultant, acknowledged that these residents did not receive or were not offered pneumococcal immunizations at the facility. The Interim Administrator confirmed that the facility's expectation was for pneumococcal immunizations to be offered to residents per federal regulations, or for there to be documentation indicating that the residents had received the immunizations in the past. The facility reported a census of 25 residents at the time of the survey.
Failure to Document COVID-19 Vaccination Offers and Statuses
Penalty
Summary
The facility failed to develop and implement adequate policies and procedures to ensure proper documentation of COVID-19 vaccination offers and statuses for residents. Specifically, the medical records of four residents, identified as Resident #3, #6, #13, and #17, lacked documentation indicating whether they were offered the COVID-19 vaccine and whether they consented to or declined the immunization. This deficiency was identified through a review of the Electronic Health Records (EHR), policy review, and staff interviews. The facility had a total census of 25 residents at the time of the survey. Resident #3 and Resident #17 were noted to have moderate cognitive impairment, with Brief Interview of Mental Status (BIMS) scores of 9 and 10, respectively. Resident #6 and Resident #13 had no cognitive impairment, with BIMS scores of 15 and 13. Despite these cognitive assessments, there was no documentation in their EHRs regarding their consent or declination of the COVID-19 vaccine. The Regional Nurse Consultant and the Interim Administrator acknowledged the oversight, confirming that these residents did not receive COVID-19 vaccinations in 2024, contrary to the facility's policy and federal regulations that require offering and documenting COVID-19 immunizations for residents.
Deficiency in CNA Continuing Education Requirements
Penalty
Summary
The facility failed to ensure that all Certified Nurse Aides (CNAs) completed the required 12 hours of continuing education annually, as evidenced by a review of personnel files and staff interviews. Specifically, two out of five CNA files reviewed lacked documentation of the required training hours. Staff E, hired on January 2, 2023, and Staff A, hired on December 27, 2023, did not have evidence of completing the necessary training. The facility's Administrator acknowledged the absence of a policy on CNA annual training requirements and mentioned that an in-service schedule had been established, with each session lasting an hour. However, the facility's Annual In-Service Calendar indicated a plan for monthly education to meet the 12-hour annual training requirement for direct care staff.
Facility Fails to Provide Warm Water in Resident Rooms
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for its residents by not ensuring the availability of warm water in residents' rooms. Multiple residents, including those with no cognitive impairment, reported that the water in their sinks was not hot enough for washing hands. Observations confirmed that the water remained cool to the touch even after being run for several minutes. The facility's maintenance supervisor admitted to not having conducted temperature checks recently due to a broken thermometer and acknowledged the issue with water temperatures in various halls. Further investigation revealed that the water temperatures in some rooms were significantly below the expected levels, with temperatures taking a long time to reach even 90 degrees. The interim administrator was unaware of any complaints but later acknowledged the water temperature concerns. A plumber's assessment indicated that the recirculators responsible for pushing hot water were not functioning properly, suggesting a longstanding issue with the facility's water heating system.
Failure to Conduct Background Check Before Hiring DON
Penalty
Summary
The facility failed to ensure that background checks were completed before hiring staff, as evidenced by the hiring of Staff G, the Director of Nursing (DON), who was listed on the Child Abuse Registry for having abused a child. The facility's policy, dated December 2024, clearly stated that they would not knowingly employ individuals found guilty of abuse, neglect, or mistreatment, and that all employees would undergo a criminal background check. However, the personnel record review revealed that there was no documentation of any follow-up inquiry into the details of why Staff G was listed on the Registry. Interviews with staff revealed a lack of communication and responsibility regarding the hiring process. Staff M, a Nurse Consultant, acknowledged that she interviewed Staff G and may have issued the offer letter but did not conduct the background check, stating it was the responsibility of the Administrator. The current Administrator reported that she contacted her superior about the abuse check results, who then reached out to the previous Administrator, who mistakenly believed the check was clean. An email to the Central Abuse Registry confirmed that no further requests were made regarding this background check, indicating a failure in the facility's hiring process and adherence to their own policies.
Failure to Complete PASARR Process and Update Care Plans
Penalty
Summary
The facility failed to complete the Pre-Admission Screening and Resident Review (PASARR) process for two residents, leading to deficiencies in their care plans. Resident #15, who had a diagnosis of Bipolar Disorder and was prescribed Caplyta, an antipsychotic medication, did not have this medication reflected in their Minimum Data Set (MDS) as required. The Assistant Director of Nursing acknowledged that the medication should have been documented as an antipsychotic on the MDS. Additionally, the Interim Administrator admitted that a new PASARR should have been completed when the resident's psychiatric diagnoses were updated, but this was not done. For Resident #21, the facility failed to incorporate the recommendations from the PASARR Level II Outcome into the resident's care plan. Despite having a diagnosis of Schizophrenia and requiring specialized services, the care plan did not reflect these needs. The Interim Administrator stated that a new PASARR was not completed because the resident was transferred from a sister facility, and she was unaware of the required supports. The facility also lacked a policy related to PASARR, contributing to the oversight.
Failure to Identify Target Behaviors for Psychotropic Medication
Penalty
Summary
The facility failed to identify target behaviors for the use of psychotropic medications for a resident with a diagnosis of bipolar disorder, alcohol-induced acute pancreatitis, and adjustment disorder with anxiety. The resident, who had intact cognition, was prescribed Caplyta and Trazadone for depression, although the Caplyta was intended for bipolar disorder. The physician orders did not specify target behaviors for these medications, and the facility did not correctly identify the purpose of the Caplyta prescription. The Assistant Director of Nursing acknowledged the error in the medication order and the lack of identified target behaviors. The Interim Administrator also recognized that medication orders should align with diagnoses and was unaware of the requirement to identify target behaviors with prescribed medications. The facility did not have a policy in place regarding the identification of target behaviors for psychotropic medication orders.
Failure to Submit Veteran Information
Penalty
Summary
The facility failed to comply with the requirement to submit information about residents who are veterans to the Iowa Department of Veterans Affairs. Specifically, the facility did not ensure that four residents, who were either admitted or discharged during the review period, completed the Veteran's Questionnaire. This questionnaire is necessary to determine eligibility for veteran benefits. The facility's oversight was identified through a review of admissions records and interviews with staff, revealing that the questionnaire was not part of the admission process for these residents. The Interim Administrator acknowledged the failure to ask residents about their veteran status upon admission, which is a requirement for facilities receiving reimbursement through the medical assistance program under Iowa Code chapter 249A. The facility also lacked a policy related to inquiring about veterans' benefits, contributing to the oversight. This deficiency affected four residents, two of whom remained in the facility, while one was discharged, and another's veteran status was not reported despite being identified as a veteran.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to uphold the dignity of three residents by not providing timely assistance with toileting and maintaining privacy. Resident #2, who had normal cognitive functioning and required total assistance for toileting, was observed waiting over 45 minutes to use the bathroom. Despite being seated in her power wheelchair outside the bathroom, staff did not promptly assist her, leading to her having to wait for extended periods, sometimes up to two hours. The Assistant Administrator of Nursing acknowledged that residents should not wait longer than 15 minutes for toileting needs, yet Resident #2 experienced significant delays. Resident #1, who was cognitively intact but dependent on staff for hygiene and toileting, reported that it often took a long time for staff to respond to her call light, resulting in her soiling herself and feeling embarrassed. The Administrator acknowledged the delay in assistance, noting that it required two staff members to help Resident #1 with toileting, which contributed to the prolonged wait times. Resident #10, who had severe cognitive impairment and required assistance with toileting, was publicly told by a CNA in the dining room that she needed to change her wet pants. This announcement was made in front of other residents, compromising her dignity. The Administrator recognized that this was not a dignified way to address the resident's needs. The facility's policy on abuse prevention defines verbal abuse as using disparaging and derogatory terms towards residents, which was violated in this instance.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate nurse staffing to meet the needs of its residents, as evidenced by the experiences of three residents. Resident #1, who was admitted for rehabilitation, reported significant delays in call light responses, often waiting 45 to 90 minutes for assistance. This resident was dependent on staff for various activities, including toileting and transfers, and expressed dissatisfaction with the delay in starting physical therapy due to a lack of proper equipment. Similarly, Resident #4, who had a moderate cognitive deficit and was at risk for skin breakdown, experienced long waits for assistance with incontinence care, which she needed frequently due to being a heavy wetter. She reported that staff would sometimes turn off her call light without providing the necessary care, citing insufficient staffing as the reason. Resident #3, who had intact cognitive ability but was dependent on staff for daily activities, also reported long wait times for call light responses. This resident, who was at risk for skin breakdown, relied on staff for peri-care after incontinence episodes. The staff's inability to respond promptly was attributed to a lack of sufficient help, as reported by the resident. The facility's staffing issues were further highlighted by the experiences of Staff D, an LPN, who worked excessively long hours, including a 23-hour shift, due to a shortage of available nurses. Staff D confirmed that there were times when only one CNA was available, and office staff rarely assisted despite promises to do so. The facility's staffing plan, as documented in their assessment, aimed for 3.00 hours per patient day (PPD) for CNA care, equating to 72 CNA hours per day for their census of 24 residents. However, this goal was not met, as indicated by the Regional Nurse Consultant, who acknowledged that the PPD calculation was unrealistic. The Director of Nursing admitted that there was no policy on call light response times, and the facility operated with minimal staffing, particularly during night shifts. This inadequate staffing led to delays in resident care and unmet needs, as reported by both residents and staff.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for 8 consecutive hours each day, as required. During a 30-day period, there were four days without RN coverage, specifically on the 9th, 10th, 17th, and 23rd of November 2024. The Director of Nursing (DON), who is a Registered Nurse, acknowledged the absence of RN coverage on these dates and mentioned discussing the issue with the Administrator. The Nurse Scheduler, Staff F, indicated difficulties in maintaining RN coverage due to a lack of on-call staff and reliance on agency nurses. Additionally, the facility did not have a policy in place regarding RN coverage, despite the facility assessment stating the need for RN or LPN coverage for each shift to provide competent support and care for the resident population.
Failure to Develop Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for a resident who was admitted for rehabilitation with the goal of returning home. Despite a care plan conference being held and the resident's needs being discussed, no care plan was documented in the electronic record as of the survey date. The resident, who was cognitively intact, expressed dissatisfaction with the lack of planning related to his admission, including inadequate equipment and delayed physical therapy, which hindered his rehabilitation progress. The resident was admitted with lower extremity impairments and was dependent on staff for various activities of daily living. Observations revealed that the resident was mostly bed-ridden for a period due to inadequate equipment and lack of timely therapy. The Director of Nursing acknowledged the absence of a care plan in the electronic record and noted that the facility did not have a specific policy on care planning, instead following general regulations.
Failure to Provide Necessary Bariatric Equipment for Resident
Penalty
Summary
The facility failed to ensure they had the proper equipment and services to meet the needs of a resident before admission, resulting in a deficiency. The resident, who was admitted with a knee injury and required therapy services, was accepted by the facility without considering his bariatric equipment needs. Upon arrival, the staff was unaware of the necessary equipment, and the resident was left without a suitable bed, commode, walker, or chair, which delayed his physical therapy and rehabilitation progress. The resident, who was cognitively intact, expressed frustration over the lack of planning related to his admission. He was mostly bed-ridden from the time of his admission until the necessary equipment arrived, which was over two weeks later. During this period, he was given bed baths and used a bedpan that was too small, leading to frequent spills. The facility's failure to provide the appropriate equipment in a timely manner resulted in the resident losing progress made in the hospital and relying on his family to purchase a suitable walker. The facility's staff, including the Administrator, DON, and ADON, were involved in the decision to admit the resident but did not adequately prepare for his equipment needs. The facility's assessment indicated that they should have obtained more information before admitting a bariatric patient over 425 pounds, yet they did not start calling for the specialized equipment until after the resident's admission. This oversight led to significant challenges in meeting the resident's care needs and contributed to the deficiency identified in the report.
Failure to Protect Resident from Abuse and Psychological Harm
Penalty
Summary
The facility failed to protect a resident from abuse and psychological harm, as evidenced by an incident involving a Certified Nursing Assistant (CNA), referred to as Staff A, who allegedly provided care in a rough manner and used inappropriate language towards the resident. The resident, who had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairments, reported feeling unsafe and fearful when Staff A was present. The resident's medical history included conditions such as cerebral palsy, anxiety, depression, and post-traumatic stress disorder (PTSD), which may have contributed to her heightened sensitivity to the alleged abuse. The incident occurred when the resident expressed dissatisfaction with the delay in being assisted to bed, leading to a verbal altercation with Staff A. Multiple staff members provided statements indicating that the resident was upset and that Staff A responded inappropriately by using profanity and dismissive language. The resident reported feeling sore after Staff A's care and expressed a desire not to be cared for by her. Despite these reports, Staff A continued to work at the facility, although she was not allowed to provide care to the resident in question. The facility's investigation revealed inconsistencies in the accounts of the incident, with some staff members corroborating the resident's claims of verbal abuse, while others denied hearing inappropriate comments. The resident's fear and discomfort were evident, as she reportedly stayed close to other staff members when Staff A was present. The facility's failure to adequately address the resident's concerns and ensure her safety contributed to the deficiency identified by the surveyors.
Failure to Timely Report Resident Abuse Allegation
Penalty
Summary
The facility failed to report a resident's allegation of abuse to the appropriate authorities in a timely manner. On the evening of 7/23/24, two staff members assisted a resident to bed, during which the resident expressed frustration over the delay in being put to bed. The resident accused one of the staff members of being verbally abusive, using inappropriate language, and making her feel uncomfortable. The incident was reported to the Assistant Director of Nursing (ADON), who is also the mother of the accused staff member. The ADON spoke with the resident and the staff involved but did not report the incident to the Director of Nursing (DON) or the State Agency immediately. The resident, who has a history of cerebral palsy, anxiety, depression, and other medical conditions, reported feeling upset and unsafe due to the staff member's behavior. The resident's mental status was assessed as unimpaired, with a Brief Interview of Mental Status (BIMS) score of 15, indicating no cognitive impairments. Despite the resident's grievances and the staff's acknowledgment of the incident, the ADON did not escalate the matter, and the facility only reported the allegation to the State Agency the following day after further prompting from other staff members. The delay in reporting the incident led to the State Agency identifying an Immediate Jeopardy situation, which was not addressed until several days later. The facility's failure to act promptly and follow proper reporting protocols contributed to the deficiency, as the resident's allegations were not taken seriously or addressed in a timely manner, potentially compromising the resident's safety and well-being.
Failure to Protect Resident from Psychosocial Harm
Penalty
Summary
The facility failed to protect a resident from psychosocial harm during and after the investigation of an alleged abuse incident. The resident, who had no cognitive impairments and a history of multiple medical conditions including cerebral palsy and PTSD, reported feeling upset and unsafe due to the behavior of a staff member, Staff A. The incident began when the resident expressed frustration over waiting two hours to be put to bed, leading to a verbal altercation with Staff A, who allegedly responded inappropriately. The facility's investigation revealed conflicting accounts of the incident. Staff A and another CNA, Staff B, were involved in the altercation, with Staff A reportedly making inappropriate comments to the resident. The resident expressed feeling unsafe and fearful of Staff A, especially when she was present in the facility. Despite the resident's grievances and visible distress, Staff A was allowed to return to work after completing education on abuse, although she was not permitted to care for the resident directly. The facility's response to the incident included an investigation and discussions with the resident, but the resident continued to feel unsafe and expressed concerns about potential retaliation. The facility's abuse prevention policy was in place, but the handling of the incident and the return of Staff A to work without adequately addressing the resident's ongoing fear and distress contributed to the deficiency.
Failure to Follow Physician Orders and Medication Administration Errors
Penalty
Summary
The facility failed to adhere to physician orders and properly administer medications for two residents, leading to deficiencies in care. For Resident #2, who has severe cognitive impairment, the facility did not apply Lidocaine cream as ordered before a wound dressing change. The registered nurse, Staff E, conducted the dressing change without applying the Lidocaine cream, which was supposed to be applied 30 minutes prior to the procedure to manage pain. This oversight was acknowledged by both Staff E and the Director of Nursing (DON), who confirmed that the medication should have been administered as per the physician's order. Additionally, the facility did not have a documented order for physician notification regarding weight gain for Resident #2, despite the After Visit Summary indicating the need to monitor for tachycardia and notify the physician if there was a significant weight gain. The resident's care plan also lacked goals or interventions related to this requirement, indicating a failure to incorporate critical physician instructions into the resident's care plan and medication administration records. For Resident #4, who has no cognitive impairment, the facility failed to transcribe an order for potassium chloride upon admission, resulting in the resident not receiving the medication for an extended period. This error was identified during a monthly medication review, and the DON admitted to not entering the potassium order with the admission orders. The facility had procedures requiring two nurses to verify admission orders, but this process failed to catch the error. The oversight was acknowledged by the DON, who noted that physician notification and lab tests were conducted after the error was discovered.
Non-Payment Issues Lead to Service Disruptions
Penalty
Summary
The facility failed to use its resources effectively and efficiently, resulting in a status of non-payment with several local vendors. This deficiency was observed through interviews with staff and vendors, as well as document reviews. Staff members reported that garbage had not been picked up for over two weeks on multiple occasions due to unpaid bills, leading to an overflow of trash. Additionally, the facility was in non-payment status with a transportation provider, causing residents to miss important medical appointments. Staff interviews revealed that the facility's administration was aware of the outstanding balances and had communicated with the corporate office regarding these issues. However, the corporate office was reportedly slow in responding and addressing the overdue payments. The facility's maintenance director and other staff members expressed frustration over the lack of communication and resolution from the corporate office, which affected the facility's ability to maintain necessary services such as waste removal and transportation. The report also highlighted specific instances where residents were directly impacted by the non-payment issues. For example, a resident missed a cardiac follow-up appointment necessary for wound healing due to the transportation provider not being paid. The facility's administrator acknowledged the non-payment status with various vendors, including waste removal, pest control, and bottled water suppliers, and noted that the transition from a third-party payment system to the home office handling payments may have contributed to the delays.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of a transfer to a hospital for two residents. Resident #1 was in the hospital from 7/29/23 through 7/31/23 and again from 8/1/23 through 8/10/23. Resident #23 was in the hospital from 1/30/23 through 2/1/23. The facility's Electronic Health Records (EHR) confirmed these hospitalizations, but the required notifications to the Ombudsman were not made. A review of the facility's document titled 'Notice of Transfer Form to Long-Term Care Ombudsman' revealed that Resident #1 was not included in the document for the relevant dates. Additionally, there was no Ombudsman notification for January of the previous year for Resident #23's transfer. Interviews with facility staff indicated that the previous Administrator was responsible for Ombudsman notifications, but this responsibility had since been assumed by Staff A in Social Services. Staff A expected Ombudsman notifications to be completed monthly with a report of residents transferred out of the facility. The current Administrator also confirmed that his expectation was for monthly notifications to include all transferred residents. However, the facility failed to adhere to its policy, as outlined in an undated document titled 'Required Discharge and Transfer Notices,' which mandates that transfer and discharge notices must be sent to the Long-Term Care Ombudsman.
Failure to Obtain Bed Hold Notifications
Penalty
Summary
The facility failed to obtain bed hold notifications for two residents during their hospital transfers. Resident #1 was hospitalized from 7/29/23 to 7/31/23 and again from 8/1/23 to 8/10/23, while Resident #23 was hospitalized from 1/30/23 to 2/1/23. The Electronic Health Records (EHR) confirmed these hospitalizations, but no bed hold forms were found for these dates. Interviews with Staff A from Social Services and the Director of Nursing (DON) revealed that the expectation was to obtain bed hold notifications every time a resident is transferred out of the facility. The facility's undated Bed Hold Policy also stated that bed hold notifications should be provided each time a resident is transferred from the facility.
Failure to Update Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to fully review and revise the comprehensive care plan for one resident. The quarterly Minimum Data Set (MDS) for the resident included diagnoses of cancer, congestive heart failure, pulmonary edema, hypertension, and cellulitis of the bilateral lower legs. The MDS indicated the resident received an anticoagulant medication within the seven-day look-back period and had intact cognition. Despite the resident's routine anticoagulant therapy prescribed for a history of an acute embolism and thrombosis of a deep vein in the right lower extremity, the care plan initiated did not include a focus for the anticoagulant medication therapy nor provide staff directives regarding therapy interventions. The Director of Nursing (DON) confirmed that the care plan should be updated within one week after a resident's status change, as per the facility's policy.
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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