Casa De Paz Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sioux City, Iowa.
- Location
- 2121 West 19th Street, Sioux City, Iowa 51103
- CMS Provider Number
- 165174
- Inspections on file
- 23
- Latest survey
- October 30, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Casa De Paz Health Care Center during CMS and state inspections, most recent first.
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 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.
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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