Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Casa De Paz Health Care Center during CMS and state inspections, most recent first.
Surveyors observed that kitchen staff failed to follow the facility’s food safety policy requiring opened food items to be labeled and dated, as evidenced by multiple unlabeled cereal containers and a large bucket of flour without open dates, as well as a half-eaten bowl of soup with a spoon stored in a freezer. A dietary aide confirmed the soup should not have been in the freezer, and the CDM and Administrator both stated their expectation that opened items be labeled and dated in accordance with the facility’s written policy.
Failure to follow hand hygiene and infection control practices during wound care was observed for a resident with right toe dressings. A RN used gloved hands to access the wound cart key and supplies, handled dressing materials in a way that contaminated the field, and repeatedly changed gloves without performing hand hygiene between glove changes. The facility's Clean Dressing Change policy emphasized hand hygiene, glove use, maintaining a sterile field, and preventing cross-contamination.
A resident who required maximal assistance with personal hygiene and had dementia and anxiety disorder had a care plan directing staff to keep fingernails short, but surveyors observed long nails with debris and old food under them. Staff interviews revealed that nail care responsibilities were divided between bath aides and nursing staff based on diabetic status, and it was confirmed that this non-diabetic resident’s nail care should have been completed by the bath aide. The DON stated she expected fingernails to be trimmed as a care issue, and the facility’s nail care policy required routine trimming and filing on a regular schedule, which was not carried out for this resident.
A resident who required moderate assistance with transfers and walking, used a walker, and had a care plan specifying one-staff assist was observed being walked from the dining area without a gait belt by a CNA, who then left the resident standing at the dining room doors. Another CNA subsequently applied a gait belt and assisted the resident to the bedroom. Staff interviews revealed that one CNA routinely used a gait belt with this resident, while the CNA who walked the resident without a gait belt was unaware the resident required assisted transfers with a gait belt, despite facility policy requiring gait belt use for residents who cannot independently ambulate or transfer.
Failure to complete a required background check before hire. For 1 of 5 employees reviewed, a CNA had a hire date before the Iowa Criminal History Record Check Request SING form was completed. The personnel file lacked documentation that the check was done prior to the employee working in the facility, and the Administrator confirmed it should have been completed before the employee started.
A resident with sleep apnea, lung disease, and obesity had a BiPAP present at the bedside and used it for naps, but the MDS and baseline care plan did not identify the device or its use. The DON reported no knowledge of the BiPAP, and the Administrator said the admission inventory process did not question the machine. The resident stated the BiPAP was brought to the facility on admission.
A resident with sleep apnea, obesity, and lung disease had a BiPAP observed at the bedside and later used for naps, but the chart lacked a physician order, machine settings, and a cleaning schedule. The MDS did not indicate use of a non-invasive ventilator, and the DON reported no awareness of the BiPAP despite the resident stating it was brought in on admission.
A resident with Parkinson's Disease received incorrect dosing of carbidopa-levodopa for 12 days after staff failed to clarify conflicting medication orders from a neurology clinic visit. The resident did not receive the prescribed extended-release formulation and required frequent PRN doses, resulting in inadequate symptom control. Staff did not promptly seek clarification despite policy requirements, and the error persisted until the correct order was obtained.
A resident with a history of Parkinson's Disease and a Duopa pump had their GJ tube left in place after the pump was no longer in use, but staff did not obtain or follow physician orders for tube maintenance or flushing. Multiple providers were unclear about who was responsible for ongoing care, and facility policy requiring clear direction for tube care was not followed, resulting in a deficiency related to the lack of monitoring and maintenance of the tube.
The facility did not ensure that hot foods were served at the required temperatures, with multiple meal trays observed below the policy standard of 140°F. Several residents with intact cognition reported that their food was often cold and unappetizing, confirming the deficiency in food service practices.
A resident with a previously negative Level I PASRR result was later diagnosed with psychotic and delusional disorders and prescribed psychotropic medications, but the facility did not update the PASRR or refer for a Level II evaluation as required by policy. Staff confirmed the oversight during interview.
Care plans for three residents were not updated to include high-risk medications, their side effects, or required precautions. One resident with severe cognitive impairment and multiple diagnoses had no documentation of non-pharmacological interventions or monitoring for side effects related to antidepressant, antipsychotic, and narcotic medications. Another resident's care plan lacked information on antipsychotic and anti-anxiety medication use and side effects. Additionally, a resident on chemotherapy and under contact and droplet precautions did not have these precautions reflected in their care plan, despite facility policy and signage indicating their necessity.
Staff failed to use required PPE, including gowns and masks, when entering the room of a resident on contact and droplet precautions for chemotherapy-related care. The resident reported that staff consistently did not wear appropriate protective equipment, and facility policy confirmed the need for such precautions.
Three residents experienced loss of personal property, including clothing and an electric razor, due to inconsistent inventory procedures and lack of follow-up by staff. Residents reported missing items to staff, with some filing grievances, but inventory lists were incomplete or not updated, and the facility did not replace lost or stolen items as per staff interviews.
A resident with severe cognitive impairment and high fall risk suffered a fall and head injury when a motion alarm, intended to alert staff, was not properly positioned and failed to activate. Additionally, two residents were transferred using a mechanical lift with the wheels braked, contrary to manufacturer instructions, potentially compromising their safety. These deficiencies were identified through observation, record review, and staff interviews.
A facility failed to properly count and verify narcotics upon delivery for four residents. A nurse signed for the medications without verifying the quantities against the packing slips, contrary to the facility's policy. The medications included morphine, belbuca, hydrocodone, and pregabalin. The ADON and DON acknowledged the oversight, citing a busy day and unfamiliarity with the task as reasons for the failure to follow proper procedures.
The facility failed to properly store medications for 19 residents after delivery, leaving them unattended and within reach of family members. Staff interviews revealed non-compliance with procedures for securing narcotics and other medications, contrary to the facility's policy requiring immediate storage in locked containers or medication carts.
The facility failed to serve food at safe temperatures, as observed during a lunch service where food items were below the required temperature. A resident reported that the food was often cold, and staff admitted to not checking temperatures after serving, contrary to facility policy.
The facility failed to maintain sanitary conditions in food storage and preparation areas. Observations revealed undated and improperly stored food items in the kitchen fridge and freezer, along with unsanitary conditions in the dry storage area, including spilled flour, dead bugs, and soiled serving scoops. The facility's cleaning and sanitizing policy was not followed, as confirmed by the Dietary Manager.
The facility failed to properly cover clean linens during transport, leading to potential contamination. A laundry aide was observed using a cart with open sides, inadequately covered by a towel, exposing linens to contamination. The facility's policy requires linens to be covered during transport, but the Administrator was unaware of this requirement.
The facility failed to complete required background checks for three staff members before they began working. These staff members started their roles without the necessary Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry, and Professional License background checks, which were only completed after their employment commenced. The facility's policy requiring these checks before onboarding was not followed.
The facility failed to ensure residents received restorative exercises as planned for four residents. Despite detailed care plans, documentation showed minimal completion of prescribed exercises. Staff interviews revealed that the Restorative Aide was often pulled to the floor, preventing the completion of restorative exercises, and the DON acknowledged the issue.
The facility failed to serve therapeutic menus as ordered, with residents on pureed diets receiving non-pureed oatmeal and residents on mechanical soft diets receiving mixed vegetables with corn. This failure involved five residents and was confirmed by the Certified Dietary Manager.
The facility failed to ensure proper food labeling, hand hygiene, and sanitary storage practices in the kitchen. Observations included undated food items, improper storage of utensils in ingredient bins, and staff not following hand hygiene protocols. The contracted CDM acknowledged the issues, and the facility's policies on sanitation and personal hygiene were not followed.
The facility failed to notify the Ombudsman office of facility-initiated discharges for three residents. One resident with intact cognition and multiple diagnoses was transferred to the hospital twice without notification. Another resident with severe cognitive impairment was hospitalized three times, and a third resident with moderate cognitive impairment was hospitalized twice, all without Ombudsman notification. The facility lacked a policy for such notifications.
The facility failed to submit a comprehensive MDS assessment within the required timeframe for a resident. The MDS Coordinator acknowledged the delay, and the Administrator was unaware of other instances of non-compliance. The submission report showed the assessment was submitted more than 14 days late. The facility did not have a specific policy for MDS completion but followed the RAI manual.
The facility failed to administer the correct dosage of medication to a resident after a medication change, resulting in the resident receiving an incorrect dosage on multiple occasions. This error was due to a computer entry mistake that allowed nurses the option to give either one or two tabs.
A resident with an indwelling suprapubic urinary catheter was observed multiple times with the catheter bag and tubing touching the floor, contrary to CDC guidelines. Despite the care plan intervention to check the tubing for kinks each shift, staff were seen pushing the resident in a wheelchair with the catheter bag dragging on the floor. The DON confirmed the issue with dignity bags splitting, leading to improper catheter care.
The facility failed to ensure a resident was free from unnecessary psychotropic medications, continuing a PRN Haloperidol order past the 14-day limit without proper reassessment or documentation. The resident, with severe cognitive deficits, received multiple doses without clear indications or documentation of effectiveness.
A resident with moderate cognitive impairment and non-Alzheimer's dementia received duplicate doses of Olanzapine due to a failure in discontinuing a higher dose. The error was identified during a medication regimen review by the pharmacist, who clarified with the physician that the resident should only be taking 7.5 mg daily. The Director of Nursing acknowledged the medication error.
The facility failed to properly measure and serve pureed food to meet the nutritional needs of three residents on a pureed texture diet. The cook did not measure the total volume of the pureed food, resulting in incorrect portion sizes being served. The CDM confirmed that the pureed food should have been measured prior to serving, as outlined in the facility's policy.
The facility failed to ensure that the binding arbitration agreement provided for the selection of a venue that was convenient to both parties for three residents. The agreements specified that disputes would be decided at an arbitration hearing at a court reporter's or attorney's office within 180 days of the request for arbitration. The Administrator acknowledged the omission and confirmed that the arbitration program guide differed from the agreement.
Failure to Label Opened Food Items and Improper Storage of Partially Consumed Food
Penalty
Summary
Surveyors identified a deficiency in food storage practices when, during a continuous kitchen observation, they found multiple food items not labeled with open dates and an improperly stored partially consumed food item. Specifically, four large plastic cereal containers and a five-gallon bucket of flour had no open dates noted, and a half-eaten bowl of soup with a spoon in it was found stored in the freezer compartment of a refrigerator/freezer. A dietary aide acknowledged that the half-eaten bowl of soup with a spoon should not have been in the freezer. The Certified Dietary Manager stated that her expectation was for items to be labeled and dated when opened and that half-eaten bowls of soup should never be in the freezer, and the Administrator similarly stated she would like to see items labeled and dated when opened. Review of the facility’s “Food Safety Requirements” policy indicated staff are required to label, date, and monitor refrigerated food, including leftovers, so it is used by its use-by date. The facility reported a census of 71 residents at the time of the survey, but the report does not identify specific residents or clinical conditions related to this deficiency.
Failure to Follow Hand Hygiene and Wound Care Infection Control Practices
Penalty
Summary
The facility failed to perform proper hand hygiene and failed to follow infection control guidelines during wound care for one resident with right toe dressings. During observation, a RN donned a gown and gloves, placed a barrier on the wound cart, and then used gloved hands to access a pocket for the wound cart key, unlock the cart, and obtain wound care supplies. The RN manually contacted kerlix and gauze while removing them from packaging and placed the items back onto the potentially contaminated barrier surface. The RN then removed and discarded gloves but did not perform hand hygiene before putting on a new pair of gloves. After removing the resident's right toe dressings, the RN again removed gloves and failed to perform hand hygiene before donning a third pair of gloves. At the end of the wound care and dressing change, the RN removed gloves, failed to perform hand hygiene, and placed supplies back into the wound cart before finally performing hand hygiene. The facility's Clean Dressing Change policy dated 2025 stated that wound care should be provided in a manner that decreases the potential for infection and cross-contamination, with emphasis on hand hygiene, glove use, maintaining a sterile field, and managing multiple wounds.
Failure to Provide Routine Fingernail Care as Planned
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of assistance with activities of daily living related to nail care for a resident who required maximal assistance with personal hygiene. Clinical record review showed that the resident’s MDS documented a need for maximal assistance and diagnoses of non-Alzheimer’s dementia and anxiety disorder, and the care plan revised on 2/19/26 directed staff to keep the resident’s fingernails short. During observation on 4/6/26 at 2:32 PM, the resident’s fingernails were noted to be long with debris under the nails. In interviews, a CNA stated that the bath aide usually cuts residents’ fingernails unless the resident is diabetic, in which case the nurse trims them, and confirmed that this resident’s nails were long with buildup and old food under them. An RN confirmed that nurses trim nails for residents with diabetes, the bath aide trims nails for other residents, and that this resident was not diabetic, so nail care would be the bath aide’s responsibility. The DON stated she would expect fingernails to be trimmed as this is a care issue. Review of the facility’s “Nail Care” policy (2025) indicated staff will complete routine nail care, including trimming and filing, on a regular schedule, which had not been done for this resident as observed.
Failure to Use Gait Belt and Follow Transfer Requirements for Assisted Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow proper transfer and ambulation techniques, specifically the use of a gait belt, for a resident who required assistance. The resident’s MDS indicated a need for moderate assistance with chair/bed-to-chair transfers, toileting transfers, and walking, and documented the use of a walker. The resident’s care plan, revised on 2/19/26, identified a self-care deficit with impaired balance during transitions and a need for assistance with walking, specifying that the resident was to be transferred with assistance from one staff member. Facility policy on gait belt use required staff to use gait belts with residents who could not independently ambulate or transfer, for safety. On observation, a CNA (Staff E) was seen walking the resident from the dining room table to the edge of the dining room without a gait belt, then leaving the resident standing at the dining room doors while she returned to the dining area. Another CNA (Staff C) then approached, applied a gait belt, and assisted the resident to his bedroom. Staff C stated she always used a gait belt when assisting this resident with transfers. Staff E stated she was unaware the resident required one-person assist with a gait belt and reported that the resident had walked by himself as long as she had worked there, confirming that the resident placed his walker out in front and leaned very far forward. An RN (Staff D) confirmed observing Staff E assist the resident with his walker and no gait belt and stated the resident was an assist with one staff and should have a gait belt when transferring. The DON also stated she would have preferred staff to place a gait belt on the resident, as he was an assist with one staff member when transferring.
Failure to Complete Required Background Check Before Hire
Penalty
Summary
The facility failed to ensure all employees had an Iowa Criminal History Record Check Request SING form completed before working in the facility for 1 of 5 employees reviewed, Staff A, a CNA. Review of the facility’s Employee New Hire by Time Period document showed Staff A had a hire date of 2/2/26, while the personnel file showed the criminal background check through the Iowa Criminal History Record Check Request SING form was completed on 4/7/26 at 11:43 a.m., after the hire date. The file lacked documentation of a background check completed prior to Staff A working in the facility. The facility policy stated that a state-specific criminal record check and dependent adult/child abuse registry check would be completed on all prospective employees prior to hire, and the Administrator confirmed in interview that the background check should have been completed before Staff A started.
Baseline Care Plan Did Not Address BiPAP Use
Penalty
Summary
The facility failed to include necessary healthcare information in the baseline care plan for Resident #46 regarding the presence and use of a BiPAP machine. Resident #46’s MDS assessment documented diagnoses of sleep apnea, lung disease, and obesity, and the resident had a BIMS score of 15, indicating no cognitive impairment. However, the MDS did not indicate that the resident used a non-invasive mechanical ventilator, and the baseline care plan also failed to show the need for or use of the BiPAP machine. Observation on 4/6/2026 at 1:37 PM showed a BiPAP on the resident’s bedside table, and later observations showed the resident also used the BiPAP for naps. In interviews, the DON reported no knowledge that the resident had or used a BiPAP at the facility, and the Administrator stated the receptionist performed resident inventory and did not question the resident having a BiPAP machine. The resident reported bringing the BiPAP to the facility when recently admitted, and the DON later confirmed the admission process required change to address BiPAP usage upon resident entry.
BiPAP Use Not Addressed
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident who had diagnoses of sleep apnea, obesity, and lung disease. The resident’s MDS assessment did not indicate use of a non-invasive mechanical ventilator, even though a BiPAP machine was observed on the resident’s bedside table and later observed being used for naps. The resident had a BIMS score of 15, indicating no cognitive impairment, and reported bringing the BiPAP to the facility when recently admitted. The resident’s clinical physician orders did not include orders, settings, or a cleaning schedule for the BiPAP machine. The DON reported no knowledge that the resident had or was using a BiPAP at the facility, and the Administrator stated the receptionist completed the resident inventory without questioning the presence of the BiPAP. The DON later confirmed the facility had obtained a physician’s order for the BiPAP and was working to secure the proper settings, and also stated that a cleaning or supply ordering schedule had not been in place.
Failure to Clarify and Transcribe Accurate Medication Orders for Parkinson's Treatment
Penalty
Summary
The facility failed to accurately transcribe and clarify medication orders for one resident with Parkinson's Disease following a neurology clinic visit. The resident, who had a history of progressive neurological condition, diabetes, anemia, and other comorbidities, required precise dosing of carbidopa-levodopa (Sinemet) and its extended-release formulation. After the clinic visit, the documentation from the neurologist contained conflicting information regarding the medication regimen, with discrepancies between the narrative, medication lists, and the plan section of the summary. Despite these inconsistencies, staff did not seek timely clarification of the orders. As a result, the resident was administered an incorrect dose of medication for 12 days. The facility's records showed that the resident received only the regular formulation and not the extended-release tablets as previously prescribed. The MAR/TAR indicated frequent use of the PRN dose, and nursing notes documented the resident's increased stiffness and inadequate symptom control during this period. The DON eventually contacted the neurologist after observing the resident's condition and the high use of PRN medication, but this was not done immediately after the conflicting orders were received. The facility's policy required clarification of unclear or incomplete orders, but staff relied on the section of the summary that stated there were no changes to the medications, overlooking the plan section that detailed the intended regimen. The administrator acknowledged the contradictory information in the neurologist's summary and confirmed that staff did not pay attention to all relevant sections. This failure to clarify and accurately transcribe the medication orders led to the resident receiving an incorrect medication regimen for an extended period.
Failure to Obtain and Implement Physician Orders for GJ Tube Maintenance
Penalty
Summary
The facility failed to request and implement physician's orders for the monitoring and maintenance of a Gastrojejunostomy (GJ) tube for a resident with a Duopa pump, resulting in a lack of clear direction for staff regarding tube care. The resident, who had a history of progressive neurological condition, Parkinson's Disease, and other significant medical issues, had a Duopa pump installed for medication administration. After the facility was unable to obtain medication cartridges, the pump was not used for over six months, but the resident wished to keep the j-tube in place for potential future use. Despite this, staff did not obtain clarification orders for the maintenance or flushing of the tube while it was not in use, and documentation on the Medication Administration Record (MAR) indicated that required flushes were not consistently completed. Interviews with facility staff and physicians revealed confusion and lack of responsibility regarding who should provide orders for the tube's maintenance. The Primary Care Physician (PCP) was unaware of the specific requirements for the Duopa pump tubing and deferred responsibility to the neurologist, while the neurologist's office stated that maintenance orders were only given while the pump was in use. The gastroenterologist who placed the tube indicated that the tubing should be replaced every six months and that maintenance orders should have been provided by the physician managing the medications. No one from the facility contacted the appropriate providers to clarify ongoing care for the tube during the period it was not in use. The facility's policy required staff to have clear direction on the frequency and volume of tube flushing, as well as guidance on tube replacement. However, these procedures were not followed, and there was no documentation of staff receiving or following specific orders for the care of the resident's GJ tube during the period it was not being used for medication administration. This lack of communication and failure to obtain and implement appropriate physician orders led to the deficiency identified during the survey.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that food was served to residents at safe and appetizing temperatures, as required by their policy. Observations showed that food items such as ham, mashed potatoes, and carrots were served below the minimum required temperature of 140°F for hot foods. Specifically, test trays and meal trays prepared for residents were found with temperatures ranging from 96°F to 131°F for various hot food items. Staff were observed serving these trays, and in one instance, a tray was returned to the kitchen for reheating after the temperature was checked and found to be inadequate. Multiple residents with intact cognition reported dissatisfaction with the food, specifically noting that it was often cold when it should be hot. These complaints were corroborated by interviews, where residents described the food as cold and unpalatable. The facility's policy requires hot foods to be served at no less than 140°F, but this standard was not met during the observed meal service.
Failure to Refer for Level II PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASRR) evaluation after the emergence of a new mental health diagnosis. Clinical record review showed that the resident, who had a negative Level I PASRR result at admission, was later diagnosed with psychotic and delusional disorders and was prescribed psychotropic medications. The Minimum Data Set (MDS) assessment documented these diagnoses, but the PASRR was not updated to reflect the new mental health condition. The facility's policy required referral for a Level II PASRR evaluation when a new or possible serious mental disorder was identified, but this was not done. Staff interview confirmed that the PASRR should have been resubmitted with the updated diagnosis.
Failure to Update Care Plans for High-Risk Medications and Precautions
Penalty
Summary
The facility failed to revise and update care plans to address high-risk medications, their side effects, and necessary precautions for three out of twenty sampled residents. For one resident with severe cognitive impairment and diagnoses including depression and dementia, the care plan did not include non-pharmacological interventions for prescribed antidepressant and antipsychotic medications, nor did it address the use of narcotic pain medication or list side effects to monitor. Another resident with severe cognitive impairment and multiple diagnoses was prescribed antipsychotic and anti-anxiety medications, but the care plan lacked documentation on medication usage, side effects, and non-pharmacological interventions prior to administering as-needed medications. The DON confirmed that high-risk medications and their side effects should have been included in the care plans, and acknowledged that narcotic medications were not typically documented in care plans at the facility. Additionally, a resident receiving chemotherapy and under contact and droplet precautions did not have these precautions documented in their care plan, despite signage at the resident's door and physician orders indicating the need for such precautions. The DON stated that care plans should include documentation of contact and droplet precautions. Facility policy requires ongoing assessment and revision of care plans as resident conditions change, but this was not followed in these cases.
Failure to Follow Contact and Droplet Precaution Protocols
Penalty
Summary
A deficiency was identified when staff failed to follow appropriate infection prevention and control practices for a resident on contact and droplet precautions. The resident, who was admitted with a diagnosis of malignant neoplasm of the rectum and receiving chemotherapy, had a physician's order for contact and droplet precautions, as indicated by signage on the resident's door. Despite these precautions, a Certified Medication Aide (CMA) was observed entering the resident's room without wearing any required personal protective equipment (PPE), including a gown, gloves, or mask, while administering medications. Further, the resident reported that staff never wore a gown or face shield when entering the room, despite being aware of the need for precautions due to ongoing cancer treatments. The Director of Nursing (DON) confirmed that the expectation was for staff to wear gowns and masks when entering rooms with droplet and contact precautions. Review of the facility's policy also confirmed the requirement for staff and visitors to wear appropriate PPE, including gowns, gloves, and goggles, under these circumstances.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to protect the personal property of three residents, resulting in missing items such as clothing and an electric razor. One resident reported missing shorts and pants, stating she had informed staff but did not file a grievance. The inventory list for this resident did not include shorts and listed ten pairs of pants. Another resident reported several missing items, including a shirt, socks, underwear, pants, and an electric razor, and stated that an inventory sheet was only completed after items began to go missing. This resident had filed grievances regarding the missing items, but the inventory list did not reflect all the missing property. A third resident reported missing bras, had informed staff, but the items were not replaced and no grievance was filed. The inventory list for this resident did not include bras. Staff interviews revealed that inventory sheets are provided to new admissions and are to be completed with assistance from staff, with updates made as necessary. The facility's policy requires that residents' belongings be inventoried upon admission and updated as needed. However, staff indicated that the facility does not replace lost or stolen items. The administrator stated that her expectation is for inventory lists to be updated and detailed, but the findings indicate that inventory procedures were not consistently followed, leading to unaddressed losses of residents' personal property.
Failure to Prevent Accidents Due to Improper Use of Motion Detector and Mechanical Lift
Penalty
Summary
The facility failed to prevent accidents and hazards in multiple instances, as evidenced by improper use of a motion detector and inadequate transfer techniques with a mechanical lift. In one case, a resident with severe cognitive impairment, high fall risk, and multiple medical diagnoses, including heart failure and osteoarthritis, experienced a fall resulting in a laceration, facial bruising, and the need for pain medication. The resident's care plan included a motion alarm as a post-fall intervention, but at the time of the incident, the motion sensor was turned on but not facing the resident, and thus did not alert staff when the resident attempted to self-transfer and fell. Staff interviews confirmed the alarm was present but not properly positioned, and the resident was found on the floor with injuries requiring emergency room evaluation and treatment. Additionally, the facility failed to use proper transfer techniques for two residents during observed transfers with a mechanical lift. Staff were observed raising and lowering residents from wheelchairs to beds while the lift's wheels were braked, contrary to the manufacturer's instructions, which specify that the wheels should remain un-braked during these maneuvers (except when lifting from the floor). The facility's policy did not align with the user manual for the current lift, and staff did not follow the correct procedure, potentially causing discomfort or risk to the residents during transfers. The deficiencies were identified through clinical record review, direct observation, resident and staff interviews, and review of facility protocols and equipment manuals. The report documents that the facility census was 66 residents at the time, and the failures involved both the improper use of safety equipment and non-compliance with manufacturer guidelines for resident transfers.
Failure to Verify Narcotics Delivery
Penalty
Summary
The facility failed to properly count and verify narcotics upon delivery from the pharmacy for four residents. On the specified date, a male pharmacy staff member delivered medications to the facility, and a registered nurse, Staff A, signed for the medications without verifying the quantities against the packing slips. The medications included morphine sulfate for one resident, belbuca for another, hydrocodone for a third, and pregabalin for a fourth resident. Staff A admitted to not checking the medications and stated that it was usually the responsibility of the overnight nurses to do so. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged that the proper procedure was not followed, which required the nurse receiving the medications to count them with the pharmacy staff member present. The facility's policy on controlled substances, revised in December 2012, mandates that controlled substances must be counted upon delivery, with both the nurse and the pharmacy staff member signing the controlled substance record. However, this procedure was not adhered to, as Staff A did not verify the medications delivered, citing a busy day and unfamiliarity with the task as reasons for the oversight. The ADON emphasized the importance of focusing on checking in medications and ensuring that narcotics are counted before other medications. The failure to follow these procedures led to the deficiency noted in the report.
Failure to Secure Medications Upon Delivery
Penalty
Summary
The facility failed to appropriately store medications for 19 residents after they were delivered from the pharmacy. Video footage showed that a male pharmacy staff member delivered medications, which were signed for by Staff A at the receptionist's desk. The medications were left unattended and unsupervised on the desk, within arm's reach of family members, before being collected by Staff B and taken to the nurse's station. The medications included controlled substances such as morphine sulfate and belbuca, which were not immediately secured in accordance with the facility's policy. Interviews with staff revealed a lack of adherence to the facility's procedures for handling and storing medications. Staff E, an RN, stated that narcotics should be placed in a lock box, while other medications should be stored in medication carts. Staff B confirmed that the medications were left unattended and that she moved them to the nurse's station. Staff A admitted that the medications should have been locked up immediately after delivery. The Director of Nursing reiterated that medications should be taken to the medication carts or placed in the overflow cart upon delivery. The facility's policy on controlled substances mandates that they be stored in a locked container in the medication room, separate from non-controlled medications, which was not followed in this instance.
Failure to Serve Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food served to residents was at a proper and safe temperature. During an interview, a resident expressed that the food was often cold and did not request reheating due to not wanting to inconvenience the staff. Observations during a lunch service revealed that the temperatures of the food items served were below the required safe temperature, with chicken at 126.1 degrees, mashed potatoes and gravy at 121.1 degrees, and mixed vegetables at 106.4 degrees, while the banana cream pie was at 33.1 degrees. Another resident confirmed that their food was cold, with only the coffee being hot. The dietary staff admitted to checking food temperatures before serving but not after, which is contrary to the facility's policy that requires maintaining food above 140 degrees Fahrenheit and measuring internal food temperature prior to serving.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure that food was stored and prepared under sanitary conditions, as observed during a kitchen tour. The kitchen fridge contained several items ready for service that were either undated or improperly stored. These included an open gallon of white milk with no open date, undated chef salads, deli sandwiches, tuna salad sandwiches, and a tube of whip topping left uncovered and undated. Additionally, thickened water, juice, and dairy drinks were found open and undated. In the kitchen freezer, ice cream was scooped into styrofoam bowls, stacked uncovered and undated. Further observations in the dry storage area revealed unsanitary conditions, including spilled flour on the floor, dead bugs along the edges of the room, and various food items such as pudding packages and a cheese puff laying on the floor under the shelving. Open and undated powdered sugar and another powdered substance were also found spilling out. Serving scoops in a drawer were soiled with food and debris, and bowls were stored improperly right side up. The facility's policy on cleaning and sanitizing, dated June 2015, mandates maintaining clean and sanitary kitchen facilities, which was not adhered to, as confirmed by the Dietary Manager during an interview.
Inadequate Linen Transport Practices
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not properly covering clean linens during transportation, leading to potential contamination. On two separate occasions, a laundry aide was observed transporting clean clothing protectors and personal clothing in a laundry cart with open sides, covered inadequately by a towel. This left the linens exposed to contamination. The facility's policy, dated March 2015, clearly states that clean linen should be covered during transport to prevent contamination. However, the Administrator was unaware of this requirement, indicating a lapse in policy enforcement and staff training.
Failure to Complete Required Background Checks Before Employment
Penalty
Summary
The facility failed to complete the required Iowa Criminal History, Iowa Sex Offender Registry, Iowa Central Abuse Registry, and Professional License background checks prior to the employment of three staff members (Staff B, C, and D). These staff members began working directly for the facility on January 14, 2024, but their background checks were only completed on January 24 and 25, 2024. The facility's Administrator confirmed that these individuals had been working in the facility's kitchen under a contract company, which did not share the necessary documentation with the facility. Despite the facility's policy requiring background checks to be completed before onboarding, this was not adhered to in these cases. The Administrator stated that the paperwork for the background checks had been submitted to the facility's corporate Human Resources Department but did not receive the results back before the employees started working. Additionally, there was a delay in receiving the ability to work documentation for Staff D, which was only approved on March 30, 2024, after a re-submission on March 26, 2024. This failure to complete the necessary background checks prior to employment is a violation of the facility's Abuse Prevention Program & Reporting Policy, which mandates screening for abuse, neglect, exploitation, and criminal records for all potential employees before hire.
Failure to Provide Restorative Exercises as Planned
Penalty
Summary
The facility failed to ensure residents received restorative exercises as planned for four residents. Resident #3, who had moderate cognitive impairment and functional limitations in both lower extremities, was supposed to receive specific therapeutic exercises as per their care plan. However, documentation showed that the resident only received upper extremity exercises once and lower extremity exercises twice in a 30-day period. Similarly, Resident #16, who had no cognitive impairment but functional limitations in both lower extremities, did not receive any restorative exercises over three months, despite the care plan specifying exercises three times per week. The resident's participation was sporadic, and refusals were documented, but no exercises were completed during the documented periods. Resident #20, who had no cognitive impairment but required assistance with daily activities and had multiple diagnoses including non-Alzheimer's dementia and chronic respiratory conditions, was also not provided with the prescribed restorative exercises. The resident's care plan included specific upper and lower extremity exercises and ambulation with a walker, but documentation showed minimal completion of these exercises over a 30-day period. Resident #37, with moderate cognitive impairment and a recent fracture, was similarly neglected in terms of restorative exercises. The resident's care plan included detailed therapeutic exercises, but records indicated that these were only performed twice in a 30-day period. Staff interviews revealed that the Restorative Aide was responsible for 36 residents and often got called to the floor, which prevented her from completing restorative exercises. The Director of Nursing acknowledged that restorative care was not being performed as it should be due to staffing issues. The facility's policy emphasized the importance of restorative nursing to help residents maintain their highest practicable level of functioning, but the documented deficiencies indicate a failure to adhere to this policy.
Failure to Serve Therapeutic Menus as Ordered
Penalty
Summary
The facility failed to serve residents the therapeutic menus as ordered for five residents. Residents with pureed diet orders were served oatmeal that was not pureed, and residents with mechanical soft diets were served mixed vegetables that included corn, which was not appropriate for their dietary needs. Specifically, Resident #25, who had a pureed diet order due to conditions such as neurogenic bladder, anemia, diabetes mellitus, cerebrovascular accident, dementia, and hemiplegia, was served oatmeal that was not pureed. Similarly, Resident #43, who had severe cognitive deficits and was dependent on staff for eating, and Resident #5, who had moderate cognitive deficits and was on a pureed diet, were also served oatmeal that was not pureed. The facility's menu indicated that pureed diets should include options like pureed hot cereal, but this was not followed during the breakfast meal observed on 4/09/24. Additionally, Residents #12 and #36, who were on mechanical soft diets, were served mixed vegetables that included corn, contrary to the menu that specified cooked carrots for mechanical soft diets. The Certified Dietary Manager (CDM) confirmed that the residents on mechanical soft diets should not have received mixed vegetables with corn. The dietary staff, including a cook who had recently transitioned from a dietary aide without proper training, were not adequately following the prescribed dietary orders, leading to the serving of incorrect food textures and types, thereby putting residents at risk for choking.
Deficiencies in Food Labeling, Hand Hygiene, and Sanitary Storage Practices
Penalty
Summary
The facility failed to ensure proper food labeling, hand hygiene, and sanitary storage practices in the kitchen. During an initial kitchen tour, surveyors observed multiple cups of fruit, a chunk of cheese, and more fruit in the walk-in refrigerator that were not dated. Additionally, the inside door of the walk-in refrigerator had white spatter. In the dry storage room, a large sugar canister had a cup stored in it, and a large flour canister had a mug in it. A follow-up kitchen tour revealed similar issues, including a case of straws sitting on the floor, a bag of watery, browning lettuce that was opened and not dated, and an opened, undated whipped topping container. The contracted Certified Dietary Manager (CDM) was also observed with hair hanging outside of her hairnet, and staff failed to complete hand hygiene before and after glove use during food preparation tasks. The CDM acknowledged the issues, stating she was aware of the lettuce in the walk-in cooler and had thrown it out. She also admitted to not checking the flour container and being focused on getting the Rueben sandwiches ready for serving when she directed Staff B to put on gloves without completing hand hygiene. The facility's policies on sanitation, personal hygiene, and refrigerator storage were not followed, as evidenced by the improper storage of scoops in ingredient bins, failure to label leftovers with dates, and inadequate hand hygiene practices. The facility had a census of 55 residents at the time of the survey.
Failure to Notify Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to notify the Ombudsman office of facility-initiated discharges for three residents. Resident #30, who had intact cognition and multiple diagnoses including anemia, coronary artery disease, and end-stage renal disease, was transferred to the hospital twice in January 2024. These transfers were not reported to the Ombudsman, and the facility lacked a policy regarding such notifications. The Administrator acknowledged this oversight during an interview on 4/10/24. Resident #25, who had severe cognitive impairment and was totally dependent on staff for certain activities, was hospitalized three times in 2023. These hospitalizations were not included in the Ombudsman notification list. Similarly, Resident #3, who had moderate cognitive impairment and diagnoses including pneumonia and septicemia, was hospitalized twice in late 2023. These hospitalizations were also not reported to the Ombudsman. The facility's failure to notify the Ombudsman of these discharges was confirmed through clinical record reviews and staff interviews.
Failure to Submit MDS Assessment on Time
Penalty
Summary
The facility failed to submit a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one resident. The review of the resident's MDS assessment revealed a lack of a transmission date. The MDS Coordinator acknowledged that the assessment had not been submitted and stated that a correction would be made. The Administrator expected MDS assessments to be completed and submitted within the required timeframes but was not aware of other instances of non-compliance. The submission report showed that the MDS assessment was submitted more than 14 days late. The facility did not have a policy for the completion of the MDS but followed the Resident Assessment Instrument (RAI) manual.
Medication Administration Error
Penalty
Summary
The facility failed to ensure that Resident #38 received medications as ordered. Despite a medication change on 2/27/24, staff continued to administer the previous order of one tab instead of the updated order of two tabs on multiple occasions (3/6, 3/17, and 3/28). This error was attributed to a computer entry mistake that allowed nurses the option to give either one or two tabs. The resident, who had a BIMS score of 14 indicating intact cognitive ability, suffered from frequent pain due to Parkinson's Disease and other conditions, and was reliant on accurate medication administration for pain management. The resident's care plan, updated on 11/12/23, indicated that staff should assess pain every shift and evaluate the effectiveness of pain interventions. However, the review of the electronic record and the hand-written Controlled Drug Administration Record revealed discrepancies in medication administration. The facility's Medication Management policy, revised on 1/20/22, stated that medications should be administered according to the resident's plan of care and efforts should be made to prevent medication errors, which was not adhered to in this case.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care to prevent urinary tract infections for a resident with an indwelling suprapubic urinary catheter. The resident, who had moderate cognitive impairment and was dependent on toileting hygiene, was observed multiple times with the catheter bag and tubing touching the floor. This occurred despite the care plan intervention to check the tubing for kinks each shift and the CDC guidelines that specify the catheter bag should not rest on the floor. The resident had a history of urinary tract infections, as noted in the progress notes documenting post-antibiotic treatment for a UTI. On several occasions, staff were observed pushing the resident in a wheelchair with the catheter bag dragging on the floor, and the dignity bag used to cover the catheter bag was noted to have slits, causing the bag to split and touch the floor. The Director of Nursing confirmed that the catheter bag and tubing should not touch the floor and acknowledged the issue with the dignity bags splitting. The facility's failure to maintain proper catheter care as per CDC guidelines was evident in these observations.
Failure to Reassess PRN Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were free from unnecessary psychotropic medications, specifically for one resident who had an order for Haloperidol as needed (PRN). The clinical record revealed that the PRN order continued past the 14-day limit for psychotropic medication use. The resident, who had severe cognitive deficits and was totally dependent on staff for transfers and eating, did not exhibit physical behavioral symptoms such as hitting, kicking, or grabbing. Despite this, the resident was administered Haloperidol multiple times without corresponding documentation of the reason for administration, indicating a lack of proper reassessment and justification for continued use of the medication. The resident's care plan included the use of psychotropic medications and directed staff to consult with pharmacy and providers for dosage reduction when clinically appropriate. However, the facility's records showed repeated administration of Haloperidol without clear documentation of the target behavior symptoms or effectiveness of the medication. The Director of Nursing acknowledged that the PRN Haloperidol order should have been reassessed after 14 days of use, as per the facility's medication management policy, which emphasizes non-pharmacological interventions and clear documentation of indications for PRN medication use.
Failure to Prevent Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors. The resident, who had moderate cognitive impairment and was diagnosed with non-Alzheimer's dementia, was prescribed Olanzapine. Initially, the resident was to receive 5 mg daily, but a new order increased the dosage to 7.5 mg daily. Despite a subsequent order to revert to 5 mg daily, the resident continued to receive both 5 mg and 7.5 mg doses due to a failure in discontinuing the higher dose. This error was identified during a medication regimen review by the pharmacist, who noted the duplication and sought clarification from the physician, who confirmed the resident should only be taking 7.5 mg daily. The Director of Nursing acknowledged the error, stating it was a medication error on their part, and it was caught by the pharmacist during the review process. The resident's care plan included monitoring for side effects and adverse reactions to psychotropic medications, but the failure to discontinue the 7.5 mg dose led to the resident receiving an extra dose. The facility's policy on medication management defines a medication error as any preventable event that may cause inappropriate medication use or resident harm, including extra dose errors. The Director of Nursing admitted that the error occurred because the 7.5 mg dose was not discontinued as required, resulting in the resident receiving duplicate doses of Olanzapine.
Failure to Properly Measure and Serve Pureed Food
Penalty
Summary
The facility failed to prepare and serve pureed food to meet the nutritional needs of three residents who were on a pureed texture diet. On the specified date, the cook pureed four Rueben sandwiches with chicken broth but did not measure the total volume of the food after pureeing to determine the appropriate portion sizes. During the noon meal service, the cook served one scoop of the pureed sandwich to each of the three residents. After the meal service, it was discovered that there were three servings left over, indicating that the portions served were incorrect. The cook acknowledged that she should have measured the pureed contents and admitted to being confused by the menu instructions. The contracted Certified Dietary Manager (CDM) confirmed that the pureed food items should have been measured prior to serving to ensure correct portion sizes. The facility's undated policy on the puree process outlined specific steps, including measuring the desired number of servings before pureeing, adding necessary thickeners or liquids, measuring the total volume after pureeing, and dividing the total volume by the original number of portions. The failure to follow these steps led to the deficiency in meeting the nutritional needs of the residents on a pureed diet.
Failure to Ensure Convenient Arbitration Venue
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement provided for the selection of a venue that was convenient to both parties for three residents. The undated Voluntary Arbitration Agreement and Program Guide, provided by the Administrator, did not include evidence for the selection of a mutually convenient venue. The agreements specified that disputes would be decided at an arbitration hearing at a court reporter's or attorney's office within 180 days of the request for arbitration. The Administrator acknowledged the omission and confirmed that the arbitration program guide differed from the agreement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sioux City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holy Spirit Retirement Home | 0.5 mi | ★★★★★ | 10 | 0 |
| Westwood Specialty Care | 1.4 mi | ★★★★★ | 16 | 0 |
| St Luke's Regional Medical Center Snf | 2.1 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Sioux City, Llc | 3.6 mi | ★★★★★ | 10 | 0 |
| Adept Nursing & Rehab Of South Sioux City | 3.8 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.