Centerville Specialty Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Centerville, Iowa.
- Location
- 1208 East Cross Street, Centerville, Iowa 52544
- CMS Provider Number
- 165225
- Inspections on file
- 20
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Centerville Specialty Care during CMS and state inspections, most recent first.
The facility failed to ensure proper hand hygiene and glove changes during wound care for two residents with multiple open wounds and MASD. In one case, an RN removed soiled dressings from both lower legs without changing gloves between legs, repeatedly changed gloves without performing hand hygiene, and handled wound products after dropping a medication cup on the floor, then continued treatment without hand hygiene. In another case, an RN cleansed two open abdominal-fold wounds with the same washcloth and changed gloves without hand hygiene before applying Triad paste to both wounds with the same fingers. Staff interviews, including with an RN, an LPN, the IP, and the DON, confirmed that facility expectations and policy required hand hygiene between glove changes and glove changes between separate wounds to prevent cross-contamination.
The facility did not obtain or document informed consent for antipsychotic medications for two residents with impaired cognition. Although staff reportedly discussed the medications with family members, there was no documentation of completed consent forms outlining the risks and benefits prior to starting the medications, as required by facility policy.
Staff did not notify the provider or perform follow-up assessments after a resident with diabetes had multiple blood sugar readings above 500 mg/dl, despite care plan directives and facility policy requiring such actions.
A resident with severe cognitive impairment and a history of falls was assisted to the bathroom by a staff member without the use of a gait belt, contrary to facility policy and the resident's care plan. During the transfer, the staff member used one hand to adjust a commode and the other to support the resident, who then stepped backward and fell, resulting in reported pain. Interviews confirmed that the gait belt, which was typically used for this resident, was not utilized during this incident.
Staff did not weigh or measure ham portions before preparing mechanical soft and pureed diets, instead estimating serving sizes and using a standard scoop that did not meet the required 5-ounce portion per the menu. Additionally, rolls were not pureed and served as required for three residents on pureed diets. These actions resulted in multiple residents not receiving correct portions or all menu items as specified.
A staff member failed to remove PPE after providing care to a resident and transported the resident in a wheelchair with indwelling catheter tubing in contact with the floor. The resident had multiple medical conditions and was dependent for all ADLs. Facility policy required PPE removal before exiting the room and keeping catheter tubing off the floor, but these protocols were not followed.
The facility failed to maintain proper kitchen sanitation and food handling practices. Observations included the Dietary Manager's hair not fully restrained, outdated turkey, and dust on fire suppression spigots. The manager handled food without washing hands after picking up refuse. Dust and food particles were found on various surfaces, and the ice machine and dishwasher had buildups. The manager acknowledged staffing struggles and cleanliness expectations.
A facility failed to provide a resident on a pureed diet with the correct portion and texture of food. The Dietary Manager served a fish filet in a pureed form but did not provide the full portion, and processed green beans to a liquid consistency instead of the required pudding consistency. The facility's policy mandates that pureed food should be of pudding consistency and that residents should receive the same amount as others.
A resident with severe cognitive impairments and a history of wandering was not treated with dignity and respect by an LPN. The LPN used raised arms and voice to redirect the resident, escalating the situation. On another occasion, the LPN physically grabbed and pushed the resident, causing him to stumble. Housekeeping staff intervened to de-escalate the situation. The facility's policy prohibits such actions and emphasizes a culture of compassion.
The facility failed to properly assess and intervene for two residents, leading to deficiencies in care. A resident with a catheter had it removed without adequate follow-up, resulting in discomfort and the need for reinsertion. Another resident experienced an unwitnessed fall, but required neurological assessments were not documented, indicating a lapse in monitoring and care protocols.
Improper Hand Hygiene and Glove Use During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene and glove use during wound care, resulting in potential cross-contamination between wounds. For one resident with congestive heart failure, diabetes, peripheral vascular disease, and multiple venous ulcers, staff did not change gloves appropriately between wounds or perform hand hygiene between glove changes. This resident was cognitively intact but dependent on staff for most ADLs and had open venous ulcer wounds on both lower legs, as well as a left heel condition and a skin tear on the left shin, all requiring specific wound care orders including cleansing with Vashe Wound Cleanser, application of Triad paste, silver dressings, and Betadine. During an observed wound care session for this resident, an RN and an LPN initially washed their hands, gowned, and gloved, and a clean field was set up. The RN removed dressings from the right and then the left leg without changing gloves between legs, despite the right leg dressing having a large amount of bloody drainage and both legs having open wounds. After removing dressings from both legs, the RN changed gloves without performing hand hygiene, while the LPN removed gloves, washed hands, and re-gloved. The RN then cleansed the right leg wounds and later removed gloves, obtained Triad paste, re-gloved without hand hygiene, and applied Triad paste with gloved fingers. After both nurses removed gloves, washed hands, and re-gloved, the RN applied dressings to the right leg. When the medication cup with Triad paste was dropped on the floor, the RN picked it up, removed one glove, obtained more Triad paste, re-gloved again without hand hygiene, and applied Triad paste to the left leg, followed by Betadine to the left heel and additional dressing applications, again changing gloves without performing hand hygiene. For a second resident with diabetes, morbid obesity, MASD, and open wounds under an abdominal fold, the RN also failed to perform hand hygiene between glove changes. This resident was cognitively intact, dependent for most ADLs, and had an open MASD wound on the right iliac crest with orders for Triad paste and Interdry to abdominal folds. During observation, the RN placed Triad paste in a medication cup, washed hands, and gloved, then exposed the abdominal area and used a wet washcloth with a small amount of hand soap to wipe two open wounds on both sides of the abdominal fold, followed by drying with a hand towel. The RN then removed gloves and donned a new pair without performing hand hygiene between glove changes and applied Triad cream to both open wounds with the same fingers. Interviews with the RN, another RN, an LPN, the Infection Preventionist, and the DON confirmed that facility expectations and policy required hand hygiene between glove changes and glove changes between wounds to prevent cross-contamination, and the hand hygiene policy specified hand hygiene before handling clean or soiled dressings, after contact with blood or body fluids, after handling used dressings, and after removing gloves.
Failure to Document Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to obtain and document informed consent for the administration of antipsychotic medications for two residents. For one resident with diagnoses including anxiety, depression, and non-Alzheimer's dementia, and a severely impaired cognition score, the clinical record showed an order for Abilify was initiated. Although a nurse's note indicated that the resident's representative was spoken to about the medication's reason and benefits, there was no documentation of a completed medication consent form outlining the risks and benefits prior to starting the medication, as required by facility policy. Similarly, another resident with moderately impaired cognition and diagnoses including diabetes, heart failure, and coronary artery disease was started on Rexulti. The care plan noted the use of antidepressant medications, but again, there was no documentation of a completed medication consent form prior to the initiation of the medication. The DON confirmed that while staff had conversations with the residents' families regarding the medications, these discussions were not documented in the clinical notes.
Failure to Notify Provider and Assess After Critically High Blood Sugar Readings
Penalty
Summary
Facility staff failed to carry out required assessments and interventions after a resident experienced multiple episodes of significantly elevated blood sugar levels. The resident, who had diagnoses including diabetes, heart failure, and coronary artery disease, had care plan directives and physician orders specifying that staff should notify the provider if blood sugar readings exceeded 500 mg/dl. Despite this, clinical records showed that on several occasions, the resident's blood sugar readings were well above this threshold. Documentation revealed blood sugar readings of 547 mg/dl and 600 mg/dl on one day, and 538 mg/dl on another, without any evidence that the provider was notified or that follow-up assessments or monitoring were conducted. The facility's policy required staff to follow physician-ordered parameters for reporting high blood sugars, but there was no documentation to show these protocols were followed. Interviews with the DON confirmed that no additional documentation or provider notification could be found regarding these incidents.
Failure to Use Gait Belt During Resident Transfer Results in Fall
Penalty
Summary
A deficiency occurred when staff failed to implement fall prevention interventions, specifically the use of a gait belt, for a resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease, non-Alzheimer's dementia, and restless leg syndrome. The resident was assessed as dependent on staff for toilet transfers and required partial to moderate assistance for walking. According to the care plan, the resident was at risk for falls and required assistance from one to two staff members for walking and transfers. Despite these documented needs and facility policy requiring the use of gait belts for safe lifting and movement, a staff member assisted the resident without a gait belt during a transfer to the bathroom. During the incident, the staff member, who was a traveling nurse, asked other staff about the resident's assistance needs and was told the resident was an assist of one. While attempting to help the resident use a commode, the staff member used one hand to adjust the commode and the other to support the resident, who then stepped backward and fell. The resident later reported pain following the fall. Interviews confirmed that the gait belt was not used during this transfer, although it was typically used for this resident. The DON confirmed that staff should use a gait belt for residents requiring assistance of one or two for transfers.
Failure to Provide Correct Portions and Follow Menu for Modified Diets
Penalty
Summary
The facility failed to ensure that residents on mechanical soft and pureed diets received the correct portions and that the menu was followed as required. Observations revealed that staff did not weigh or measure the ham portions before processing them to mechanical soft and pureed consistencies. Instead, staff estimated the portion sizes and used a standard scoop size, which did not align with the menu requirement of a 5-ounce serving of ham for each resident. Additionally, staff did not provide rolls to residents on pureed diets as required by the menu, as they forgot to puree the rolls with the ham. Interviews with staff confirmed that the correct procedures for measuring and serving portions were not followed. The dietary manager stated that the process should involve measuring meat portions before processing and using a chart to determine serving size, but this was not done. The facility's policy also directed staff to ensure correct portions and to include all menu items, such as bread, in pureed diets. These failures resulted in five residents not receiving the correct portions and three residents not receiving all menu items as specified.
Failure to Remove PPE and Maintain Catheter Hygiene During Resident Transport
Penalty
Summary
Staff failed to implement the Infection Prevention and Control Program (IPCP) by not properly removing personal protective equipment (PPE) after providing resident care and by allowing indwelling catheter tubing to contact the floor during resident transport. Specifically, a physical therapy assistant was observed wearing PPE while assisting a resident in his room and then transporting him in a wheelchair to the shower room without removing the gown. During this transport, the resident’s indwelling catheter tubing was observed in contact with the floor. The staff member admitted to keeping the gown on because she anticipated needing it again for further care in the bathroom and was unaware that the catheter tubing had touched the floor. The resident involved had multiple diagnoses, including atrial fibrillation, heart failure, diabetes, thyroid disorder, arthritis, stroke, urinary tract infection, and acute cystitis with hematuria, and was dependent on staff for all activities of daily living and mobility. Facility policies required staff to remove PPE before exiting a resident’s room and to ensure catheter tubing and drainage bags were kept off the floor. Interviews with the infection preventionist and director of nursing confirmed that staff should have removed PPE before leaving the resident’s room, and policy review indicated that enhanced barrier precautions should be followed in certain situations outside the resident’s room, but not in hallways unless specific care activities were being performed.
Inadequate Kitchen Sanitation and Food Handling Practices
Penalty
Summary
The facility failed to maintain adequate kitchen sanitation and food handling practices during two separate visits to the kitchen. During the initial kitchen tour, it was observed that the Dietary Manager's hair was not fully restrained under a hair net, and an opened package of turkey breasts was dated two weeks prior. Dust particles were hanging from the fire suppression system spigots. On a subsequent visit, the same dust was observed on the spigots, and the Dietary Manager was seen picking up refuse from the floor and then touching food without washing her hands. Additionally, the plastic menu holder, steam table, and a shelf above the steam table were found to be dusty and sticky, with loose food particles hanging over the food. Further observations revealed that the Dietary Manager retrieved ice cream from the freezer without washing her hands before serving meals. The ceiling above the sink was covered with dust-like particles, and a fire suppression system spigot above the spices and clean plates was covered with a thick layer of dust. The dishwasher had a crusty white buildup, and a drawer contained crumbs and a black substance in the corners. The ice machine had a brown buildup on the interior wall and a white buildup on the exterior. The Dietary Manager acknowledged the staffing struggles and the expectation for cleanliness, stating that all hair should be restrained under a hair net.
Deficiency in Pureed Diet Consistency and Portioning
Penalty
Summary
The facility failed to ensure that a resident on a pureed diet received the correct portion and texture of food. During an observation, the Dietary Manager (DM) processed a fish filet to a pureed consistency and served it to the resident, leaving 1/4 of a cup remaining, indicating the resident did not receive the full portion. Additionally, the DM processed green beans to a liquid consistency, which was not in accordance with the facility's policy that required pureed food to be of pudding consistency. The DM acknowledged that the resident should have received the entire fish filet and that the pureed food should not be runny. The facility's undated policy on Puree Technique directed staff to follow the menu as planned, process the correct number of portions, and ensure pureed food is of pudding consistency.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by interactions between a Licensed Practical Nurse (LPN) and a resident with severe cognitive impairments and a history of wandering and aggression. The resident, who had diagnoses including Non-Alzheimer's dementia and aphasia, was observed by housekeeping staff to be wandering the halls, a behavior noted in his care plan. On one occasion, the LPN attempted to redirect the resident by standing in front of him with raised arms and a raised voice, which escalated the situation. Despite an offer from a housekeeper to intervene, the LPN continued to interact with the resident in a manner that was not calm or respectful. Further incidents were reported where the LPN physically grabbed the resident by the arms to redirect him away from the front door and later from a room, actions that were described as aggressive. During one of these interactions, the resident began hitting the LPN, who then pushed the resident hard enough that he stumbled and almost fell, although the LPN prevented the fall. Housekeeping staff intervened by engaging the resident in an activity, which helped to de-escalate the situation. The facility's policy strictly prohibits abuse and emphasizes the importance of staff education and a culture of compassion, which was not adhered to in these interactions.
Deficiencies in Resident Monitoring and Care
Penalty
Summary
The facility failed to ensure appropriate assessment and intervention for two residents, leading to deficiencies in their care. Resident #5, who had an intact cognitive status and was dependent on maximal assistance for various needs, had a catheter removed on a trial basis. Despite the resident's preference to have it removed in the morning, there was a lack of documentation and follow-up by Staff E, an LPN, regarding the resident's voiding status. Although Staff E claimed the resident had voided a little, other staff and the resident's family reported no voiding occurred. This led to the reinsertion of the catheter by another nurse, which resulted in the return of 400 milliliters of urine, indicating a failure to monitor and address the resident's condition adequately. Resident #6, who was independent with some assistance and had a history of pneumonia, diabetes, and COPD, experienced an unwitnessed fall. The facility's protocol required frequent neurological assessments, including vital signs, which were not properly documented by Staff E and Staff F. Despite indications that vital signs were completed, there were no corresponding records in the PointClickCare system. This lack of documentation and adherence to protocol highlights a deficiency in the facility's monitoring and care practices for residents who have experienced falls.
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 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.
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.
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.
Two residents who were cognitively impaired and dependent on staff for personal care did not receive bathing assistance at least twice weekly as required by facility policy. Facility records showed multiple instances where bathing was documented as refused or not applicable, resulting in gaps of 6, 7, and 11 days between baths. The care plan for one resident specified total dependence on staff for bathing, and the facility’s policy required showers to be offered at least twice weekly and on the next available day if missed. The DON reported that staff are expected to continue offering showers and try different approaches after refusals, but the documented bathing intervals did not reflect this practice.
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.
A resident with COPD, pneumonia, and respiratory failure was transferred to the hospital for acute respiratory distress and later deemed medically ready for discharge, but the facility delayed readmission by three days due to staffing and admission timing practices. Facility staff, including an RN, MDS coordinator, ADON, DON, and Administrator, reported that they avoided weekend and evening admissions, required two nurses for admissions, and were concerned about entering medication orders into the EMR in time for pharmacy delivery when only one nurse was on duty. They did not notify the provider about the planned discharge back, did not arrange alternative pharmacy or transport options, and cited shared transport and lack of additional nurses as reasons the readmission was not feasible, despite the facility’s stated commitment to 24-hour nursing care and medication management.
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.
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.
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 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.
Failure to Provide Twice-Weekly Bathing for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide bathing assistance at least twice weekly, as required by its own policy, for two residents who were dependent on staff for bathing. For one resident with anxiety disorder, depression, and a BIMS score of 12 indicating moderate cognitive impairment, the MDS documented total dependence on staff for bathing. Facility documentation showed that bathing was recorded as refused on one date, with actual baths provided on dates that resulted in a 6‑day interval without a bath on two separate occasions. The resident’s care plan indicated the resident was totally dependent on staff to provide a bath as necessary. For another resident with diagnoses including need for assistance with personal care, lack of coordination, hypertension, and a BIMS score of 6 indicating severe cognitive impairment, facility records showed multiple dates where bathing was documented as refused or as not applicable. Review of the Follow Up Question Report demonstrated several extended gaps between baths: 6 days on two occasions, 7 days on one occasion, and 11 days on another, despite the facility policy requiring showers to be offered at least twice weekly and, if missed, to be offered on the next available day. In an interview, the DON stated that when a resident refuses a shower, staff are expected to continue to offer, try multiple times, try a different person, and continue to try the next day until the resident bathes, which was not reflected in the documented bathing intervals for these two residents.
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.
Delayed Hospital Readmission Due to Insufficient Nursing Staff and Admission Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient nursing staff and related processes to support the timely readmission of a hospitalized resident, resulting in a three-day delay in the resident’s return. The resident had moderately impaired cognition, with a BIMS score of 12/15, and medical diagnoses including COPD with acute exacerbation, pneumonia, and respiratory failure. The resident was transferred to the hospital after staff observed labored respirations, use of accessory muscles, diaphoresis, an oxygen saturation of 85% on room air, and wheezing, with improvement after oxygen was applied but continued labored breathing. Hospital records show the resident was admitted and later determined medically stable and ready for discharge, with documentation that the patient was planned for discharge but was not accepted back to the facility due to timing issues and would remain in the hospital over the weekend. Hospital progress notes documented that the resident was medically ready for discharge and that discharge was planned but not completed because the facility would not accept the resident later in the day. A hospital case management/social work note indicated confirmation that the facility could take the patient on the day the resident ultimately returned. The facility’s EHR showed the resident’s billing status changed to STOP BILLING on the date of hospital transfer and back to active several days later, corresponding to the delayed readmission. The resident reported spending three days in the hospital before being able to return to the facility. Multiple staff interviews described facility practices that contributed to the delay in readmission. An RN stated the facility tried not to do admissions on weekends and did not want admissions after 2 p.m. so nurses could complete admission tasks and enter medications into the computer in time for pharmacy delivery. The MDS Coordinator stated the facility liked residents readmitted before 2 p.m. to obtain medications, that the hospital had informed them the resident would not return until early evening, and that the facility needed two nurses in the building for an admission; the coordinator also stated the facility did not do admissions on weekends and was unsure about using another pharmacy or family to obtain medications. The ADON and DON both stated that with only one nurse on duty, a readmission later in the day was not feasible due to the time needed for admission assessments and medication entry, and they cited concerns about not having medications on time and the workload of one nurse caring for existing residents and completing a readmission. The DON further stated the facility did not accept evening or Saturday admissions for safety reasons, did not notify the provider about the planned discharge back to the facility, and did not explore hospital-supplied medications or alternative transport options, while acknowledging the presence of on-call nurses. The Administrator confirmed that with only one nurse, a readmission was considered not doable. The facility lacked written transportation or readmission policies and relied on general CMS and Resident Rights guidance, while its Resident Handbook stated residents receive individualized 24-hour nursing care and medication management.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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